Financial and Administrative Alignment Demonstrations
for Dual Eligible Beneficiaries Compared: States with
Memoranda of Understanding Approved by CMS
MaryBeth Musumeci
Using new authority in the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is
launching demonstrations that seek to improve care and control costs for people who are dually eligible for
Medicare and Medicaid. These three year demonstrations, implemented beginning in July 2013, are
introducing changes in the care delivery systems through which beneficiaries receive medical and long-term
care services. The demonstrations also are changing the financing arrangements among CMS, the states, and
providers. As of July 2014, CMS has finalized memoranda of understanding (MOUs) with 12 states to
implement 13 demonstrations:1
Figure 1
State Demonstration Proposals to Align Financing and/or
Administration for Dual Eligible Beneficiaries, July 2014
 California, Illinois, Massachusetts,
Michigan, New York, Ohio, South
VT
WA*
ME
ND
MT
NH
Carolina, Texas, and Virginia are
MN
OR
MA
NY*
WI
SD
ID
RI
MI
testing a capitated financial
CT*
PA
WY
NJ
IA*
DE
OH
NE
alignment model;
NV
IN
IL
MD
UT
 Colorado is testing a managed feefor-service (FFS) financial alignment
model;
 Washington is testing both a
capitated financial alignment model
and a managed FFS financial
alignment model; and
 Minnesota is testing the integration
of administrative functions without
financial alignment.
AK
CA
AZ
CO*
KS
OK*
NM
WV
MO*
AR
AL
SC
GA
LA
FL
HI*
NOTES: *CO, CT, IA, MO, and NC proposed managed
FFS models. NY, OK, and WA proposed both capitated
and managed FFS models; both demonstrations are
approved in WA; NY withdrew its managed FFS
proposal. All other states proposed capitated models.
SOURCE: CMS Financial Alignment Initiative, State
Financial Alignment Proposals,
http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareC
oordination.html,
and state websites.
DC
NC*
TN
MS
TX
VA
KY
MOU signed with CMS to implement financial alignment demonstration (11 states)
MOU signed with CMS to implement administrative alignment demonstration (1 state)
Proposal pending with CMS (5 states plus NY’s DD proposal)
Proposal submitted, will not pursue financial alignment but may pursue
administrative alignment (1 state)
Proposal withdrawn (8 states)
Not participating in demonstration (24 states and DC)
New York’s proposal to test a capitated model for beneficiaries with developmental disabilities (DD) who
require long-term services and supports (LTSS) and proposals from five other states are pending with CMS
(Figure 1).
This issue brief compares key provisions of the approved demonstrations (summarized in Table 1 on the next
page with additional details by state in the Appendix).
State
Target Populationa and Geographic Area
Financial
Model
CA
Estimated
Number of
Eligible
Beneficiaries
456,000
Earliest
Effective
Enrollment
Date
April 2014
Savings Percentage Applied to Medicare
and Medicaid Contributions to Baseline
Capitated Rateb
Adult dual eligible beneficiaries in 8
counties
Capitated
CO
48,000
Adult dual eligible beneficiaries
statewide
Managed
FFS
August or
September
2014
N/A (state shares savings with CMS
retrospectively if savings and quality
criteria met)
IL
135,825
Adult dual eligible beneficiaries in 21
counties grouped into 2 regions
Capitated
March
2014
1% in year 1;
3% in year 2;
5% in year 3;
MA
90,240
Non-elderly adult dual eligible
beneficiaries in 1 partial and 8 full
counties
Capitated
October
2013
0 in 2013,
1% in 2014 (remainder of year 1)d;
2% in year 2;
>4% in year 3e
MI
100,000
Adult dual eligible beneficiaries in 25
counties grouped into 4 regions
Capitated
January
2015
1% in year 1;
2% in year 2;
4% in year 3, except that year 3 savings
will be 3% if at least 1/3 of plans have
losses exceeding 3% of revenues in year 1
MN
36,000
Dual eligible beneficiaries age 65 and
over enrolled in the Minnesota Senior
Health Options program statewide
N/Af
September
2013
N/A (Minnesota’s demonstration will test
the integration of administrative functions
without financial alignment)
NY
170,000
Adult dual eligible beneficiaries in 8
counties who require nursing facility or
nursing facility diversion and transition
home and community-based waiver
services or more than 120 days of
community-based LTSSg
Capitated
January
2015
1% in year 1;
1.5% in year 2;
3% in year 3, except that year 3 savings
will be 2.5% if at least 1/3 of plans have
losses exceeding 3% of revenue in year 1h
OH
115,000
Adult dual eligible beneficiaries in 29
counties grouped into 7 regions
Capitated
May 2014
1% in year 1;
2% in year 2;
4% in year 3;
SC
53,600
Dual eligible beneficiaries age 65 and
over statewide who live in the
community at the time of enrollment
Capitated
July 2014
Same as Ohio
TX
168,000
Adult dual eligible beneficiaries with
disabilities who qualify for SSI or
Medicaid waiver HCBS in 6 counties
Capitated
March
2015
1.25% in year 1.a;i
2.75% in year 1.b;j
3.75% in year 2;
5.5% in year 3
VA
78,600
Adult dual eligible beneficiaries in 104
localities grouped into 5 regions
Capitated
April 2014
Same as Michigank
WA
21,000
High cost/high risk adult dual eligible
beneficiaries statewide except in 2
urban counties
Managed
FFS
July 2013
Same as Colorado
27,000
Adult dual eligible beneficiaries in 2
urban counties
Capitated
February
2015
1% in year 1;
2% in year 2;
3% in year 3
1% minimum,
1.5% maximum in year 1;
2% minimum,
3.5% maximum in year 2;
4% minimum,
5.5% maximum in year 3c
(See next page for Table Notes and Sources)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
2
Table 1 Notes and Sources:
Notes: a See the Appendix for subpopulations excluded from each state’s demonstration. b Demonstration savings in
the capitated models will be derived upfront by reducing CMS’s and the state’s respective baseline contributions to
the plans by a savings percentage for each year. c California’s maximum demonstration-wide savings percentages,
along with county-specific interim savings percentages, will be used to determine the demonstration’s risk corridors.
d Massachusetts reduced its 2013 savings from 1% to zero. Demonstration year 1 in Massachusetts begins in 2013 and
runs through December 2014. e Massachusetts anticipates savings of greater than 4% (approximately 4.2%) in year 3
to make up for forgone savings in year 1. f Minnesota’s administrative alignment demonstration will take place in its
existing capitated delivery system in which Medicaid MCOs also qualify as Medicare Advantage D-SNPs. g New
York’s capitated proposal for beneficiaries who have DD and need LTSS remains pending with CMS. h This
determination will be based on at least 15 months of data (demonstration year 1 in New York encompasses July 2014
through December 2015). i Demonstration year 1.a in Texas is March to Dec. 2015. j Demonstration year 1.b in Texas
is 2016. k This determination will be based on at least 20 months of data and in all regions in which plans participate
(demonstration year 1 in Virginia encompasses February 2014 through December 2015).
Sources: CMS Financial Alignment Initiative, State Financial Alignment Demonstration Memoranda of
Understanding, http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html; see also endnotes 13, 24, 33, 38, 39, 40, 58,
72, and 81.
Dual eligible beneficiaries include seniors and non-elderly people with significant disabilities, some of whom
are among the poorest and sickest beneficiaries covered by either Medicare or Medicaid. The predominant
existing service delivery models for these beneficiaries typically involve little to no coordination between the
two programs. Dual eligible beneficiaries account for a disproportionate share of spending in the Medicare and
Medicaid programs.2 In the case of Medicare, this is mainly due to their relatively poorer health status, which
requires higher use of medical services compared to other program beneficiaries. In the case of Medicaid, dual
eligible beneficiaries’ relatively high spending is generally attributable to their greater need for LTSS.
Three states’ (Colorado, Minnesota, and South Carolina) demonstrations are statewide, while the others are
limited to certain regions.
The states’ target populations for their demonstrations vary, with eight states (California, Colorado, Illinois,
Michigan, Ohio, Texas, Virginia, and Washington’s capitated model) including both elderly and non-elderly
beneficiaries. Among the states targeting sub-populations:
 Massachusetts targets non-elderly people with disabilities;
 Minnesota’s administrative alignment demonstration targets elderly beneficiaries;
 South Carolina targets elderly beneficiaries who live in community-based settings at enrollment;
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
3
 New York focuses on elderly and non-elderly beneficiaries who receive nursing facility services or nursing
facility diversion and transition home and community-based waiver services or who require more than 120
days of community-based LTSS;
 Texas targets elderly and non-elderly beneficiaries with disabilities who qualify for Supplemental Security
Income (SSI) benefits or certain Medicaid home and community-based waiver services for seniors and adults
with physical disabilities; and
 Washington’s managed FFS model targets high cost/high risk beneficiaries with chronic conditions.
Michigan is the only capitated demonstration state to include beneficiaries with DD.
CMS has stated that it plans to limit enrollment in the demonstrations to no more than two million dual
eligible beneficiaries nationally. As of July 2014, CMS has approved 13 demonstrations in 12 states in which an
estimated nearly 1.5 million beneficiaries are eligible to enroll. (Not all beneficiaries who are eligible to
participate in the demonstrations are expected to enroll.) The estimated number of beneficiaries eligible for
California’s demonstration is over 30 percent of the total number of beneficiaries eligible for all
demonstrations approved to date and exceeds the number of eligible beneficiaries in each of the other states
with approved demonstrations. Enrollment in Los Angeles County, capped at 200,000 beneficiaries, will be
greater than the number of beneficiaries eligible to participate in any of the other demonstration states (Figure
2).
Figure 2
CMS Has Approved 13 Financial and/or Administrative Alignment
Demonstrations in 12 States, in which Nearly 1.5 Million Dual Eligible
Beneficiaries Will Be Eligible to Enroll, as of July 2014
Minnesota*
36,000
Colorado
48,000
Washington Capitated
27,000
Washington Managed FFS
21,000
California
counties
other than L.A.
256,000
South Carolina
53,600
Virginia
78,600
Massachusetts
90,240
Total=
1,499,265
beneficiaries
Los Angeles
County
200,000*
Michigan
100,000
Ohio
115,000
Illinois
135,825
All California
demonstration
counties
456,000
New York
170,000
Texas
168,000
NOTES: *Enrollment in Los Angeles County is capped at 200,000 beneficiaries. Unlike the other states’ demonstrations,
Minnesota’s demonstration will integrate administrative processes but will not align financing.
SOURCE: CMS/State Memoranda of Understanding, available at http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
4
Enrollment already has begun in Washington’s managed FFS demonstration (July 2013), Massachusetts
(October 2013), Illinois (March 2014), California and Virginia (April 2014), and Ohio (May 2014). The earliest
effective enrollment dates in the other demonstrations are scheduled as follows: South Carolina (July 2014);
Colorado (August or September 2014); Michigan and New York (January 2015); Washington’s capitated
demonstration (February 2015); and Texas (March 2015) (Figure 3). (Minnesota’s administrative alignment
demonstration affects beneficiaries who are already enrolled in the state’s Senior Health Options program and
began in September 2013.)
Earliest Effective Enrollment Dates in
Financial/Administrative Alignment Demonstrations for
Dual Eligible Beneficiaries, as of July 2014
July
2013:
WA*
April
2014:
CA
VA
Oct.
2013:
MA
Sept.
2013:
MN*
March
2014:
IL
Jan.
2015:
MI
NY
July
2014:
SC
May
2014:
OH
Aug.
or
Sept.
2014:
CO
Figure 3
March
2015:
TX
Feb.
2015:
WA*
NOTES: *July 2013 = WA’s managed FFS demonstration; Feb. 2015 = WA’s capitated demonstration. MN’s demonstration
is administrative only, without financial alignment.
SOURCE: CMS/State Memoranda of Understanding, available at http://www.cms.gov/Medicare-MedicaidCoordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
Nearly all of the capitated demonstrations (some counties in California, plus Illinois, Massachusetts, Michigan,
New York, Ohio, South Carolina, Texas, Virginia and Washington) begin with a voluntary enrollment period in
which beneficiaries can “opt in” to the demonstration and select a managed care plan. The voluntary
enrollment period is followed by passive enrollment periods in which the remaining beneficiaries will be
automatically assigned to a managed care plan. In other California demonstration counties, beneficiaries will
be automatically enrolled in the demonstration without an initial voluntary enrollment period. To effectuate
passive enrollment, states are to develop “intelligent assignment” algorithms to preserve continuity of
providers and services when assigning beneficiaries to plans.
Beneficiaries retain the right to opt out of the demonstration at any time but must take affirmative action to do
so. In all states, beneficiaries can opt out of the demonstration and choose another delivery system (i.e., FFS,
Medicare Advantage, Program of All-Inclusive Care for the Elderly (PACE)) for their Medicare benefits.
However, states may seek CMS approval to require beneficiaries to enroll in Medicaid managed care even if
they opt out of the financial alignment demonstration for their Medicare benefits, and five states with capitated
demonstrations (California, Illinois, New York, Ohio, and Texas) have indicated that they are doing so. By
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
5
contrast, five states with capitated demonstrations (Massachusetts, Michigan, South Carolina, Virginia, and
Washington) allow beneficiaries who opt out of the demonstration to remain in the FFS delivery system for
both their Medicare and Medicaid benefits (Table 2).
State
Managed Care Enrollment Required for:
Medicare
Medicaida
California
No
Yesb
Illinois
No
Yesc
Massachusetts
No
No
Michigan
No
No
New York
No
Yesd
Ohio
No
Yese
South Carolina
No
No
Texas
Virginia
No
No
Yesf
No
Washington
No
No
NOTES: a CMS approval is necessary for states to require beneficiaries to enroll in Medicaid managed care, even if
beneficiaries opt out of the financial alignment demonstration for their Medicare benefits. b California’s § 1115 waiver was
amended to require beneficiaries to enroll in managed care plans for their Medicaid benefits, including LTSS. c Illinois has a
draft § 1115 waiver application seeking to require Medicaid managed care enrollment. d New York’s § 1115 waiver
requires beneficiaries in the financial alignment demonstration geographic area who receive more than 120 days of LTSS to
enroll in a Medicaid MLTSS plan. e Ohio’s MOU indicates that the state may seek additional § 1915(b)/(c) waiver authority
to require beneficiaries to enroll in Medicaid managed care. f Texas’s existing § 1115 waiver requires adult dual eligible
beneficiaries to enroll in Medicaid managed LTSS.
SOURCE: KCMU analysis of states’ financial alignment demonstration memoranda of understanding with CMS, available at
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
Given the complexities of the enrollment decision, beneficiaries are likely to need individual in-person options
counseling to make their choice.3 Five states (California, Illinois, Massachusetts, Virginia, and Washington)
have received CMS funding to date to support beneficiary outreach, education, and options counseling in their
demonstrations through their State Health Insurance Program and Aging and Disability Resource Centers.4
In Washington’s managed FFS demonstration, beneficiaries are automatically enrolled in a health home
network but retain the choice about whether to receive Medicaid health home services; other Medicare and
Medicaid services will continue to be provided on a FFS basis. Similarly, in Colorado’s managed FFS
demonstration, beneficiaries will be automatically assigned to the Regional Care Collaborative Organization in
their geographic area to access care coordination services but may disenroll from the demonstration at any
time.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
6
Minnesota’s administrative alignment demonstration does not involve passive enrollment; instead enrollment
in Senior Health Options plans remains voluntary, although the demonstration will test an integrated
enrollment system.
The ten states with capitated demonstrations are using managed care plans to coordinate services for
beneficiaries through a person-centered planning process. Person-centered planning focuses on the strengths,
needs, and preferences of the individual beneficiary instead of being driven by the care delivery system.5
Some states require or allow their managed care plans to contract with other entities to provide services in
their demonstrations (Table 3). Massachusetts requires its plans to contract with community-based
organizations to provide Long-Term Supports coordinators as independent members of the beneficiary’s care
team, Michigan requires its plans to contact with existing Prepaid Inpatient Health Plans (PIHPs) to provide
behavioral health services, and Ohio requires its plans to contract with Area Agencies on Aging to coordinate
home and community-based waiver services for enrollees over age 60. (Illinois, New York, South Carolina,
Texas, Virginia, and Washington’s capitated MOUs do not include any similar requirements). California
requires its plans to establish MOUs with county behavioral health agencies to provide specialty mental health
services and with county social services agencies to coordinate In Home Supportive Services (IHSS).
Demonstration managed care plans in Los Angeles County are subcontracting with other Medicare Advantage
plans to offer a variety of benefits packages to enrollees in California’s demonstration.
Washington’s managed FFS demonstration is using Medicaid health home care coordination organizations to
manage services among existing Medicare and Medicaid providers, and Colorado will use its existing Medicaid
Accountable Care Collaborative program to coordinate Medicare and Medicaid services for beneficiaries in its
demonstration.
Minnesota’s administrative alignment demonstration maintains the existing Senior Health Options program
delivery system in which Medicaid managed care plans contract with the state and also are qualified as
Medicare Advantage Special Needs Plans focused on dual eligible beneficiaries (D-SNPs) under contract with
CMS.
Ten states (California, Illinois, Massachusetts, Michigan, New York, Ohio, South Carolina, Texas, Virginia, and
Washington) are testing CMS’s capitated financial alignment model, in which managed care plans will receive
capitated payments from CMS for Medicare services and the state for Medicaid services.
Anticipated program savings in the capitated financial alignment demonstrations are deducted up-front from
CMS’s and the state’s respective baseline contributions to health plans by a savings percentage for each year
(Table 1). CMS will contribute the Medicare portion of the capitated rate. The Medicaid portion of the
capitated rate includes both the federal and state funding.6 None of the MOUs explicitly states the basis for the
savings percentages, although Illinois’ MOU notes that it currently has one of the highest rates of potentially
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
7
avoidable hospital admissions among dual eligible beneficiaries nationally and one of the highest proportions
of spending on institutional services compared to HCBS. While California’s MOU specifies minimum savings
percentages of 1% in year one, 2% in year two, and 4% in year three, it also includes maximum savings
percentages of 1.5% in year one, 3.5% in year two, and 5.5% in year three, making the maximum savings
percentages in California among highest of the approved demonstrations to date. Texas’s MOU specifies
savings percentages of 1.25% in year 1.a (March to December 2015), 2.75% in year 1.b (2016), 3.75% in year 2,
and 5.5% in year 3.
All 10 capitated financial alignment demonstrations include provisions to withhold a portion of the capitated
rate that plans can earn back if specified quality measures are met. California also requires its plans to provide
incentive payments from the quality withhold funds to county behavioral health agencies based on
achievement of service coordination measures, and Michigan requires its plans to reward the PIHPs that will
provide behavioral health services when the plan earns the withheld payment. South Carolina plans must
provide financial incentives to providers that achieve NCQA patient-centered medical home certification.
Two states (Colorado and Washington) are testing CMS’s managed FFS model in which providers will continue
to receive FFS reimbursement for both Medicare and Medicaid-covered services. Any savings in these
demonstrations will be determined retrospectively, with the state eligible to share in savings with CMS if
savings targets and quality standards are met.
Minnesota’s administrative alignment demonstration will not test one of CMS’s financial alignment models.
Instead, Minnesota’s Senior Health Options program will maintain its existing capitated integrated payment
and delivery system arrangements involving Medicaid MCOs that also qualify as Medicare Advantage D-SNPs.
Plans will be allowed to integrate Medicare and Medicaid primary care payments to promote care coordination
through health care homes and improved coordination among primary, acute, and LTSS and among physical
and behavioral health services.
The 10 capitated financial alignment demonstrations include nearly all Medicare and Medicaid services in the
plans’ benefits package and capitated payment. All states include nursing facility services in the plans’
capitated payment and benefits package. Eight of the 10 states testing the capitated model (Illinois, Michigan,
New York, Ohio, South Carolina, Texas, Virginia, and Washington) include beneficiaries who receive services
through certain Medicaid HCBS waivers, while two states (California and Massachusetts) exclude all HCBS
waiver enrollees from their demonstrations. Plans are allowed to offer additional benefits, outside the
traditional Medicare and Medicaid benefits packages, as appropriate to beneficiary needs. All states require
their health plans to offer beneficiaries the option to self-direct their LTSS (Table 3).
Five of the capitated states require plans to offer additional benefits as part of the demonstration.
Massachusetts plans must offer certain diversionary behavioral health and community support services that
are not otherwise covered as well as expanded Medicaid state plan benefits. Ohio’s MOU indicates that its
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
8
anticipated § 1915(b)/(c) waiver application is expected to include expanded Medicaid state plan benefits and
additional HCBS. California’s demonstration includes dental, vision, and non-emergency medical
transportation benefits, and its plans may offer additional HCBS. South Carolina’s demonstration includes a
palliative care benefit for enrollees with a serious, chronic or life-threatening illness who may not meet hospice
criteria. Michigan’s plans must offer adaptive medical equipment and supplies, community transition services,
fiscal intermediary services (to support self-direction), personal emergency response systems, and respite
services (Table 3).
Washington’s managed FFS demonstration adds Medicaid health home services but does not otherwise change
the existing Medicare and Medicaid benefits packages. Similarly, Colorado offers care coordination services
but otherwise does not change the existing Medicare and Medicaid benefits packages.
Minnesota’s administrative alignment demonstration will continue to provide Medicare benefits at least
equivalent to the basic benefit levels included in Medicare Parts A, B, and D and Medicaid benefits based on
existing Medicaid MCO contracts.
CMS has announced a funding opportunity for states with approved MOUs to support the planning,
development, and provision of independent ombudsman services in the demonstrations, with six states
(California, Illinois, Massachusetts, Ohio, Virginia, and Washington) awarded funding to date.7 Four states
(California, Ohio, Texas, and Washington’s capitated model) indicate that existing state ombuds offices will
offer individual advocacy and independent systemic oversight in their demonstrations, and five states’ (Illinois,
Michigan, New York, South Carolina, and Virginia) MOUs indicate that they intend to support an independent
ombuds program for their demonstrations. Massachusetts and California have selected their demonstration
ombudsman.8
Washington’s managed FFS MOU does not mention an ombuds program, while Colorado has created an
alliance of existing organizations to provide education and advocacy for demonstration enrollees.
Minnesota’s MOU provides that the state’s managed care ombudsman will provide input on plan and systemwide performance but does not provide further details.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
9
State
Nursing
facility
services
included
Home and
communitybased waiver
services
included
No
DD
population/
services
included
Traditional Medicaid
benefits package expanded
Plans can
offer
supplemental
benefits
Selfdirection
option
required
Required
contracting/service
coordination
CA
Yes
No
Yes – plans must provide
dental, vision and nonemergency medical
transportation services
Yes
Yes
No
Not mentioned in MOU
Yes
Yes
Yes
Yes (except
DD)
No (may seek
to include in
future)
Yes – plans must have
MOUs with county
mental health and
substance use agency
for behavioral health
services and county
social service agency for
IHSS
Not mentioned in MOU
IL
Yes
MA
No
Yes – plans must provide
diversionary behavioral
health and community
support services and
(unspecified) expanded
Medicaid state plan benefits
Yes
Yes
MI
Yes
Yes
Yes
Yes
Yes
NY
Yes
No*
Yes
Yes
Not mentioned in MOU
OH
Yes
Yes (NF
diversion and
transition
waiver only)
Yes (except
DD)
Yes – plans must provide
adaptive medical equipment
and supplies, community
transition services, fiscal
intermediary for selfdirection, personal
emergency response
system, respite
Not mentioned in MOU
Yes
Yes
Yes – plans must
contract with AAA to
coordinate HCBS for
beneficiaries over age 60
SC
Yes
Yes – expects to require
plans to provide
(unspecified) expanded
Medicaid state plan benefits
and additional HCBS
Yes – plans must provide
palliative care benefit
No
Yes – plans must provide
Long-Term Supports
coordinator form
independent communitybased organization as a
member of the care
team
Yes – plans must
contract with PIHP for
behavioral health
services
Yes (elderly/
No
Yes
Yes
Not mentioned
disabled,
HIV/AIDS, and
mechanical
ventilation
waivers only)
TX
Yes
Yes (seniors
No
Not mentioned in MOU
Yes
Yes
Not mentioned
and people
with physical
disabilities
who meet NF
level of care
only)
VA
Yes
Yes (elderly/
No
Not mentioned in MOU
Yes
Yes
Not mentioned
disabled with
consumer
direction
waiver only)
WA
Yes
Yes (except
No
Not mentioned in MOU
Yes
Yes
Not mentioned
DD)
NOTES: *NY’s capitated proposal for beneficiaries who have DD and need LTSS is pending with CMS.
SOURCE: KCMU analysis of states’ financial alignment demonstration memoranda of understanding with CMS, available at
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupportStatesEffortsinCareCoordination.html.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
in MOU
in MOU
in MOU
in MOU
10
All of the capitated demonstration states will provide beneficiaries with a single integrated notice of appeal
rights, and the existing Part D appeals process will continue to apply in all demonstrations. Minnesota’s
administrative alignment demonstration is building on the integrated appeals system already established in its
Senior Health Options program by adding a single integrated notice of appeal rights and standardizing the
timeframes to request Medicare and Medicaid appeals. By contrast, Colorado and Washington’s managed FFS
demonstrations do not make any changes to the existing Medicare and Medicaid appeals systems.
One of the capitated financial alignment demonstrations (New York) includes a fully integrated four level
appeals process for all services traditionally covered by Medicare Parts A and B and Medicaid. New York
requires its demonstration health plans to continue providing benefits while appeals are pending for both
prior-approved Medicare and Medicaid services if the beneficiary so requests within 10 days of the date of the
notice. (Continued benefits pending appeal is currently available under federal law for Medicaid services but
not for Medicare services.)
Five of the capitated demonstration states (Illinois, Massachusetts, South Carolina, Virginia, and Washington)
require beneficiaries to first exhaust an internal health plan appeal before proceeding to external appeals, while
four of the capitated demonstration states (California, Michigan, Ohio, and Texas) allow beneficiaries to choose
whether to first file an internal health plan appeal or instead to proceed directly to a fair hearing for Medicaidcovered services.
Eight of the capitated demonstrations states (Illinois, Massachusetts, Michigan, Ohio, South Carolina, Texas,
Virginia, and Washington, in addition to New York, described above) require health plans to continue Medicare
and Medicaid benefits while internal health plan appeals are pending; beneficiaries may request that Medicaid
benefits continue while fair hearings are pending, but Medicare benefits will not continue during external
appeals. California’s demonstration does not currently provide for continued Medicare benefits pending
appeal. California’s MOU provides that the existing Medicare and Medicaid appeals processes will continue at
least through demonstration year one, and the state will work to create a more integrated appeals process in
future years.
As the demonstrations are implemented, additional details about several features are emerging, including how
beneficiaries are being notified, counseled, and enrolled; how the demonstrations are being monitored and
overseen; how beneficiary ombuds programs are being implemented; and how the demonstrations are being
evaluated. CMS has contracted with RTI International to conduct an overall evaluation of the demonstrations
as well as state-specific evaluations. The MOUs provide that the evaluations will include site visits, analysis of
program data, focus groups, key informant interviews, analysis of changes in quality, utilization, and cost
measures, and calculation of savings attributable to the demonstrations. The evaluation findings are to be
reported quarterly, although there is likely to be a lag in data availability.
The approved MOUs provide additional information about how CMS and the states envision the
demonstrations working and insight into the framework and policy decisions that CMS may apply when
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
11
developing MOUs with other states that submitted proposals. Additional details are specified in the three-way
contracts between CMS, the state, and demonstration plans in the capitated model,9 in the states’ final
demonstration agreement with CMS in the managed FFS model,10 and in policy guidance. Key areas to
consider as the demonstrations are implemented include:
 how beneficiaries are making their enrollment choices;
 what the actual sources of program savings will be;
 how beneficiaries’ access to medically necessary services and supports is being ensured;
 how the demonstrations are affecting beneficiary access to HCBS;
 how beneficiaries are navigating the demonstrations’ grievance and appeals processes;
 whether continuity of care and intelligent assignment provisions are sufficient to prevent care disruptions
and the extent to which beneficiaries’ current providers are participating in demonstration health plan
networks;
 how plans and providers are accommodating the needs of beneficiaries with disabilities; and
 what impact the demonstrations are having on care quality and health outcomes.
While the demonstrations offer the potential opportunity to improve care coordination, lower program costs,
and achieve outcomes such as better health and the increased use of HCBS instead of institutional care, at the
same time the high care needs of many dual eligible beneficiaries increases their vulnerability when care
delivery systems are changed.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
12
The following tables summarize the major elements of the financial alignment demonstrations for dual eligible
beneficiaries for the states with memoranda of understanding approved by CMS. As of July 2014, the 13
demonstrations in 12 states include:
 California
 Colorado
 Illinois
 Massachusetts
 Michigan
 Minnesota
 New York
 Ohio
 South Carolina
 Texas
 Virginia
 Washington (managed FFS model)
 Washington (capitated model)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
13
MOU Signed:
March 27, 2013
3-way contract issued12
Demonstration
Duration:
3 years
April 1, 201413 to Dec. 31, 2016
Target Group:
Includes: an estimated 456,000 full benefit dual eligible beneficiaries age 21 and older in
8 counties are eligible to enroll; enrollment is capped at 200,000 in Los Angeles county;
PACE, AIDS Healthcare Foundation, and enrollees in certain § 1915(c) HCBS waivers may
participate if they disenroll from their existing program
Excludes: dual eligible beneficiaries with other comprehensive coverage, those who
receive services from a regional center, state developmental center or ICF/DD, certain
long-term care beneficiaries with a Medicaid share of cost, veterans’ home residents,
residents in certain rural zip codes, and beneficiaries with end stage renal disease in
certain counties unless already enrolled in a separate plan operated by a demonstration
prime contractor
Geographic
Area:
8 counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San
Mateo, and Santa Clara
Enrollment:
California’s revised enrollment timeline is as follows: 14
April 2014: all beneficiaries currently in Medicare FFS and Medicaid managed care in San
Mateo county and those in MSSP in San Mateo county will be passively enrolled in one
month; voluntary enrollment period begins for beneficiaries currently in Medicare FFS in
Los Angeles, Riverside, San Bernardino, and San Diego counties
May 2014: all beneficiaries currently in Medicare FFS and Medicaid managed care in
Riverside, San Bernardino and San Diego counties are passively enrolled in one month;
passive enrollment begins by birth month for beneficiaries currently in Medicare FFS and
Medicaid FFS in Riverside, San Bernardino, and San Diego counties (except that April
birthdays enroll in May 2014)
July 2014: all beneficiaries currently in Medicare FFS and Medicaid managed care in Los
Angeles county are passively enrolled in one month (passive enrollment will be in
CareMore, Care First, Molina, and Health Net plans only; L.A. Care will be eligible for
passive enrollment once it improves its Medicare quality rating); 15 12 month passive
enrollment period by birth month begins for beneficiaries currently in Medicare FFS and
Medicaid FFS in Los Angeles county
August 2014: all beneficiaries currently in MSSP in Los Angeles, Riverside, San
Bernardino, and San Diego counties are passively enrolled in one month
Jan. 2015: all beneficiaries in Medicare FFS and Medicaid managed care in Alameda and
Santa Clara counties, MSSP beneficiaries in Alameda, Orange, and Santa Clara counties,
and beneficiaries in Medicare Advantage plans in all 8 demonstration counties are
passively enrolled in one month; start of 12 month passive enrollment period by birth
month for beneficiaries in Medicare FFS and Medicaid managed care in Orange county and
for beneficiaries in Medicare FFS and Medicaid FFS in Alameda and Santa Clara counties
L.A. County enrollment is capped at 200,000, and a waiting list will be maintained.
Notices will be sent 90, 60, and 30 days prior to passive enrollment.
Beneficiaries in certain rural zip codes where only one demonstration plan operates and
those in certain non-profit prepaid health plans are exempt from passive enrollment
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
14
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
CMS approved the amendment to California’s existing § 1115 waiver,16 which requires
beneficiaries to enroll in a Medicaid managed care plan if they opt out of the financial
alignment demonstration
Passive enrollment intelligent assignment process based on 12 months of Medicare and
Medicaid claims history data to identify most frequently used providers and to ensure that
beneficiaries in long-term care facilities will not need to change facilities
Financing:
Capitated with minimum savings percentage (1% in year one, 2% in year two, and 4% in
year three) applied upfront to baseline Medicare and Medicaid contributions; for purposes
of California’s risk corridors (see endnote 20), the MOU also specifies county-specific
interim savings percentages and demonstration-wise maximum savings percentages of
1.5% in year one, 3.5% in year two, and 5.5% in year three; capitation rate withhold (1% in
year one, 2% in year two, 3% in year three) which plans earn back by meeting specified
quality measures
Plans must provide incentive payments from quality withhold funds to county behavioral
health agencies based on achievement of service coordination measures
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Parts A and B = blend of Medicare Advantage benchmarks (including quality bonus
payments) and Medicare FFS standardized county rates weighted by whether beneficiaries
who are expected to transition to the demonstration are enrolled in Medicare Advantage
or Medicare FFS in the prior year; Medicare Advantage risk score coding intensity
adjustment factor will apply after calendar year 2013;17 Part D = national average monthly
bid amount plus average projected low income cost sharing subsidy and average
projected federal reinsurance amounts
CMS Hierarchical Condition Categories model used for Medicare Advantage plans
Medicaid capitation rates under § 1115 waiver that would apply to beneficiaries who are
in target population but not enrolled in the demonstration (excluding specialty behavioral
health services financed and managed by county behavioral health agencies and costs for
county administration of In Home Supportive Services)
Medicaid risk
adjustment:
Rating categories with financial incentives for HCBS over institutional care18 to be
implemented in each county in 3 phases19
Risk sharing:
Limited risk corridors in all years20
Care Delivery
Model:
Cal MediConnect plans will provide person-centered medical homes, care coordination
and integrated medical, behavioral health, and LTSS
Requires behavioral health MOU with county mental health and substance use agency and
MOU with county social services agency to coordinate In Home Supportive Services
Prime contractor plans may subcontract with other Medicare Advantage plans to offer
multiple plan benefit packages
Participating
Health Plans:
-Alameda County (2 plan model county): Alameda Alliance Complete Care and Anthem
Blue Cross
-Los Angeles County (2 plan model county): Health Net and L.A. Care (L.A. Care partner
plans include CareMore, Care First Health Plan, and Kaiser Permanente)
-Orange County (county organized health system): CalOptima OneCare
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
15
-Riverside County (2 plan model county): Inland Empire Health Plan and Molina Dual
Options
-San Bernardino County (2 plan model county): Inland Empire Health Plan and Molina Dual
Options
-San Diego County (geographic managed care): Care First Health Plan, Community Health
Group Communicare Advantage, Health Net, and Molina Dual Options
-San Mateo County (county organized health system): Health Plan of San Mateo Care
Advantage
-Santa Clara County (2 plan model county): Anthem Blue Cross and Santa Clara Family
Health Plan
Benefits:
Includes all Medicare and Medicaid services except Medicare hospice and certain §
1915(b) specialty mental health and substance use services that will continue to be
financed and administered by county behavioral health agencies; includes In Home
Supportive Services although counties will continue to assess and authorize the need for
these services and enroll providers; plans may provide additional HCBS and behavioral
health services to prevent institutionalization as appropriate to beneficiary needs; adds
dental, vision, and non-emergency medical transportation services
Continuity of
Care:
Beneficiaries must maintain current providers and service authorizations for up to 6
months for Medicare services and up to 12 months for Medicaid services except for IHSS
providers, DME, medical supplies, transportation, and other ancillary services
Ombuds
Program:
California’s state Medicaid managed care ombuds office will support individual advocacy
and independent systemic oversight for the demonstration with an emphasis on
community integration, independent living and person-centered care. California has been
awarded CMS funding to support its ombuds program21 and has selected Legal Aid Society
of San Diego as the primary contractor for the ombuds program.22
Stakeholder
Engagement:
Plans must establish at least one consumer advisory committee that provides input to the
governing board and include beneficiaries with disabilities in the plan governance
structure
Appeals:
Notice: single integrated notice
Timeframe to request initial appeal: 60 days for Medicare-covered service; 90 days for
Medicaid-covered service
Internal health plan appeal: appeals for services traditionally covered by Medicare and by
Medicaid are to be integrated over time; for demonstration year 1 and until a new system
is established, current Medicare and Medicaid managed care appeals processes continue:
initial Medicare appeal is filed with health plan; initial Medicaid appeal is filed with health
plan or beneficiary may directly request fair hearing; California will work with CMS and
stakeholders to create a more integrated appeals process in future years, with 90 days to
request an appeal and a requirement that beneficiaries exhaust health plan and external
reviews before requesting a fair hearing
External Medicare appeals: health plan automatically sends appeal to Medicare
Independent Review Entity (IRE) if initial denial upheld; beneficiary may then request
Office of Medicare Hearing and Appeals review
External Medicaid appeals: beneficiary may request fair hearing directly or after internal
health plan appeal; beneficiaries may request Independent Medical Review for certain
Medicaid appeals if a fair hearing has not already been requested
Appeals where Medicare and Medicaid services overlap: to be determined in 3-way
contract; beneficiaries will retain right to Medicaid fair hearing
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
16
Continued benefits pending appeal: current rules continue to apply (available for Medicaid
services but not for Medicare services)
Medicare Part D appeals: existing Medicare Part D appeals process continues
Existing appeals process for county-authorized IHSS and behavioral health services also
remains unchanged.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
17
MOU Signed:
Feb. 28, 2014
Final demonstration agreement not yet available
Demonstration
Duration:
3 years
Aug. or Sept., 2014 to Dec. 31, 2017
Target Group:
Includes: an estimated 48,000 full benefit dual eligible beneficiaries without other public
or private health insurance are eligible to enroll
Excludes: beneficiaries residing in an ICF/DD; beneficiaries enrolled in Medicare
Advantage, PACE, Denver Health Medicaid Choice Plan or Rocky Mountain Health Plan and
those participating in the CO House Bill 12-1281 ACC Program Payment Reform pilot may
participate if they disenroll from their existing program
Geographic
Area:
Statewide, divided into 7 regions:
Region 1: Archuleta, Delta, Dolores, Eagle, Garfield, Grand, Gunnison, Hinsdale, Jackson,
La Plata, Larimer, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt,
San Juan, San Miguel, and Summit counties
Region 2: Cheyenne, Kit Carson, Lincoln, Logan, Morgan, Phillips, Sedgwick, Washington,
Weld, and Yuma counties
Region 3: Adams, Arapahoe, and Douglas counties
Region 4: Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, Fremont,
Huerfano, Kiowa, Lake, Las Animas, Mineral, Otero, Prowers, Pueblo, Rio Grande, and
Saguache counties
Region 5: Denver
Region 6: Boulder, Broomfield, Clear Creek, Gilpin, and Jefferson counties
Region 7: El Paso, Elbert, Park, and Teller counties
Enrollment:
Beneficiaries will be passively enrolled in the Regional Care Collaborative Organization
(RCCO) serving their geographic area and to a primary care medical provider (PCMP) based
on existing beneficiary-provider relationships.
Enrollment will be phased-in over 6 months with no more than 7,500 beneficiaries
enrolled per month. Beneficiaries will be categorized by RCCO, county, delivery system
(community relatively well, waiver, high waiver, skilled nursing facility), and provider type
(based on Medicare and Medicaid claims history: existing PCMP in Accountable Care
Collaborative (ACC) program, Medicare-Medicaid primary care providers not yet in ACC
program, Medicare primary care providers without Medicaid billing id number).
Enrollment is as follows:
Month 1: community relatively well with ACC PCMPs
Month 2: remainder of community relatively well with ACC PCMPs; community relatively
well with Medicare-Medicaid providers not yet in ACC
Month 3: remainder of community relatively well with Medicare-Medicaid providers not
yet in ACC; those receiving waiver services with ACC PCMPs
Month 4: remainder of community relatively well and those receiving waiver services with
Medicare-Medicaid providers not yet in ACC
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
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Month 5: remainder of those receiving waiver services and those receiving high waiver
services with Medicare-Medicaid providers not yet in ACC or with Medicare primary care
provider with no Medicaid billing id number
Month 6: those in skilled nursing facilities
Month 7: remainder of skilled nursing facilities
Newly eligible beneficiaries will be assigned on a monthly basis
For purposes of calculating shared savings, beneficiaries must be assigned to the
demonstration within 9 months of implementation (except for newly eligible beneficiaries)
Beneficiaries can opt out of the demonstration at any time.
CMS must approve Colorado’s § 1932 Medicaid state plan amendment to expand the ACC
program to dual eligible beneficiaries
Financing:
Managed FFS; providers continue to receive FFS reimbursement; state eligible for
retrospective performance payment if savings targets and quality standards met
Medicare
baseline for
capitated
payments:
N/A
Medicare risk
adjustment:
N/A
Medicaid
baseline for
capitated
payments:
N/A
Medicaid risk
adjustment:
N/A
Risk sharing:
N/A
Care Delivery
Model:
Colorado will expand its existing ACC Medicaid managed FFS program to include dual
eligible beneficiaries. In the ACC, RCCOs offer care coordination through RCCO staff or
arrangements with local providers; develop a network of participating PCMPs; and will
establish informal arrangements with ancillary providers. PCMPs receive per member per
month payments and must offer increased access to beneficiaries, such as extended
office hours or same-day appointments. RCCOs and PCMPs will work together with the
state to integrate and coordinate primary, acute, prescription drug, behavioral health, and
LTSS.
For beneficiaries attributed to a PCMP, RCCO will perform in-person screening and
develop care plan to coordinate services.
For beneficiaries whose primary care provider is not currently participating in the ACC
program, the RCCO will conduct outreach to involve the provider. If outreach efforts are
unsuccessful, and the beneficiary would like greater benefit from the ACC Program, the
state and RCCO will assist the beneficiary with finding a participating PCMP.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
19
Participating
Health Plans:
Region 1: Rocky Mountain Health Plan
Regions 2, 3, and 5: Colorado Access
Region 4: Integrated Community Health Partners
Region 6: Colorado Community Health Alliance
Region 7: Community Care of Central Colorado
Benefits:
No changes to existing Medicare and Medicaid benefits
Continuity of
Care:
Beneficiaries are not required to change providers and retain access to their current
choice of Medicare and Medicaid providers
Ombuds
Program:
A beneficiary rights and protections alliance will provide beneficiary education, assistance,
and advocacy. Alliance members include the state Medicaid agency, the 7 RCCOs, LTC
ombudsman, Medicaid managed care ombudsman, SHIP, CO Center on Law and Policy,
and CO Cross-Disability Coalition. Permanently invited alliance participants and guests
include CMS regional office, CO Legal Services, Demonstration Advisory Subcommittee
beneficiaries, and Medicare Quality Improvement Organization.
Stakeholder
Engagement:
State will provide opportunities for beneficiaries to provide input and participate in the CO
Medicare-Medicaid Enrollees Advisory Subcommittee, the ACC Program Improvement
Advisory Committee, the Community Living Advisory Group, and the Nursing Facility
Culture Change Accountability Board.
Appeals:
No changes from existing Medicare and Medicaid appeals systems.
Demonstration enrollees also can access the ACC complaint process, which includes
addressing service complaints with a primary care provider or RCCO, contacting the
Medicaid Managed Care Ombudsman about unresolved complaints, and requesting a state
fair hearing if beneficiary believes that services are wrongfully denied.
The state, RCCOs and other beneficiary rights and protections alliance members will
provide beneficiary education about enrollee rights and assist enrollees in exercising
grievance and appeal rights.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
20
MOU Signed:
Feb. 22, 2013
3-way contract signed Nov. 5, 201323
Demonstration
Duration:
3 years
March 1, 201424 to Dec. 31, 2016
Target Group:
Includes: an estimated 135,825 full benefit dual eligible beneficiaries age 21 and older in
21 counties grouped into 2 regions are eligible to enroll; Medicare Advantage enrollees in
a plan whose parent organization is not offering a demonstration plan may participate if
they disenroll from their existing plan
Excludes: dual eligible beneficiaries with other comprehensive coverage, those with
developmental disabilities who are served through an ICF/DD or § 1915(c) HCBS waiver,
those on a Medicaid spend down, and those in the Medicaid breast and cervical cancer
program
Geographic
Area:
21 counties grouped into 2 regions:
Greater Chicago region: Cook, Lake, Kane, DuPage, Will, and Kankakee counties
Central Illinois region: Knox, Peoria, Tazewell, McLean, Logan, DeWitt, Sangamon, Macon,
Christian, Piatt, Champaign, Vermilion, Ford, Menard, and Stark counties
Enrollment:
Initial enrollment period is voluntary, followed by a six month passive enrollment period
in which the remaining beneficiaries in the target population will be automatically
enrolled;25 passive enrollment not to exceed 5,000 beneficiaries per plan per month in
Greater Chicago and 3,000 in Central Illinois
The MOU provides that beneficiaries may begin to elect voluntary enrollment 60 days
prior to an effective date of March 2014 (as revised), followed by six groups of passive
enrollment over six months: initial notice will be sent to one group per month, with
passive enrollment effective for one group per month 60 days after notice (with the
enrollment for the first passive group effective, as revised, in June 2014)26
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
The MOU provides that Illinois must submit a Medicaid state plan amendment to
implement managed care and concurrent authority for its § 1915(c) waiver – while the
MOU does not mention mandatory Medicaid managed care, questions and answers
released by the state indicate that beneficiaries receiving LTSS will be required to enroll in
a Medicaid managed care plan;27 in addition, Illinois has a draft § 1115 waiver application
seeking to require Medicaid managed care enrollment 28
Intelligent assignment for passive enrollment will consider previous managed care
enrollment, historic provider utilization, and in year one will equalize enrollment in all
MCOs
Financing:
Medicare
baseline for
capitated
payments:
Medicare risk
Capitated with savings percentage (1% in year one, 3% in year two, and 5% in year three)
applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality
withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Same as California, except that Medicare Advantage risk score coding intensity
adjustment factor will apply after calendar year 2014
Same as California
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
21
adjustment:
Medicaid
baseline for
capitated
payments:
Medicaid risk
adjustment:
Historical state spending for state plan and HCBS waiver services trended forward
Risk sharing:
Required minimum medical loss ratio of 85%
Rating categories with financial incentives for HCBS over nursing facility care29
Care Delivery
Model:
Medicare-Medicaid Alignment Initiative plans will provide medical homes, integrated
primary and behavioral health care services, and care management; the intensity of care
management services will depend on the beneficiary’s risk level
Participating
Health Plans:
-Greater Chicago region: Aetna (not participating in Lake County; participation approval
on hold in Kankakee County), HealthSpring (not participating in Kankakee County),
Healthcare Service Company/Blue Cross Blue Shield, Humana, IlliniCare/Centene, and
Meridian (not participating in Kankakee County; participation approval on hold in DuPage
and Lake Counties)
-Central Illinois region: Health Alliance Medical Plan and Molina (participation approval on
hold in McLean, Sangamon, and Macon counties)30
Benefits:
Includes all Medicare and Medicaid services except Medicare hospice; includes Medicaid
home and community-based waiver services except for beneficiaries with developmental
disabilities; plans have discretion to offer flexible benefits as appropriate to beneficiary
needs
Continuity of
Care:
Beneficiaries have a 180 day transition period for continuing a current course of treatment
with out-of-network providers including behavioral health and LTSS
Ombuds
Program:
Illinois’s MOU indicates that it intends to support an independent ombuds program for
the demonstration. Illinois has been awarded CMS funding to support its ombuds
program.31
Stakeholder
Engagement:
Plans must establish an independent beneficiary advisory committee that meets quarterly
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: 60 days
Internal health plan appeal: all initial appeals must be filed with health plan; appeals to
be resolved within 15 business days (standard) or 24 hours (expedited)
External Medicare appeals: same as California (health plan automatically sends appeal to
Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare
Hearing and Appeals review)
External Medicaid appeals: beneficiary may request fair hearing within 30 days of plan
appeal decision for Medicaid services and within 30 days of IRE decision for overlapping
Medicare-Medicaid services; to be resolved within 90 days
Appeals where Medicare and Medicaid services overlap: to be defined in 3-way contract;
will automatically be sent to IRE, and if IRE decision not wholly favorable to beneficiary,
may request fair hearing or ALJ hearing
Continued benefits pending appeal: health plans must provide continuing benefits for
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
22
Medicare Parts A and B and Medicaid services while internal health plan appeals are
pending; beneficiaries may request continuing benefits (within 10 days) for Medicaid and
overlapping Medicare-Medicaid services while fair hearings are pending
Medicare Part D: same as California (existing Medicare Part D appeals process continues)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
23
MOU Signed:
Aug. 22, 2012;
3-way contract signed July 16, 201332 (initial term through Dec. 31, 2014)
Demonstration
Duration:
3 years
Oct. 1, 201333 to Dec. 31, 2016
Target Group:
Includes: an estimated 90,240 full benefit dual eligible beneficiaries ages 21 to 64 in 8
full counties and 1 partial county34 are eligible to enroll; Medicare Advantage, PACE, and
Independence at Home enrollees may participate if they disenroll from their existing plan
Excludes: dual eligible beneficiaries with other comprehensive coverage, ICF/DD facility
residents, and § 1915(c) HCBS waiver participants
Geographic
Area:
9 counties: Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth (partial),
Suffolk, Worcester
Enrollment:
Initial enrollment period is voluntary, followed by passive enrollment periods in which the
remaining beneficiaries in the target population will be automatically enrolled except that
no passive enrollment will take place in counties served by only one demonstration health
plan (Essex, Franklin, Middlesex, Norfolk, Plymouth)
Beneficiary outreach began in September 2013, with October 2013 as the earliest effective
date for voluntary enrollment, followed by passive enrollment in Hampden, Hampshire,
Suffolk, and Worcester counties (total 45,019 beneficiaries subject to auto-assignment):35
initial notice sent in Oct. 2013 for first passive group (an estimated 8,600 beneficiaries in
community-other rating category) with enrollment effective January 2014.36 As of Feb. 1,
2014, 9,541 beneficiaries were enrolled, and 16,642 beneficiaries had opted out of the
demonstration.37 The effective enrollment date for the second passive enrollment group
is April 2014 (an estimated 6,400 beneficiaries in the high community need, high
community behavioral health, and community-other rating categories) and July 2014 for
the third passive group.38 Beneficiaries receive notices 60 and 30 days prior to passive
enrollment.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
Massachusetts is using § 1915(a) authority to enroll dual eligible beneficiaries in Medicaid
managed care.
Intelligent assignment for passive enrollment will prioritize continuity of providers and/or
services
Financing:
Capitated with savings percentage (0 in 2013, 1% in 2014 (remainder of year one), 39 2% in
year two, and >4% in year three40) applied upfront to baseline Medicare and Medicaid
contributions; capitation rate quality withhold same as in California (1% in year 1, 2% in
year 2, 3% in year 3)
Medicare
baseline for
capitated
payments:
Same as California
Medicare risk
adjustment:
Same as California
Medicaid
baseline for
capitated
Historical state spending data trended forward
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
24
payments:
Medicaid risk
adjustment:
Rating categories41 and high cost risk pools for certain Medicaid LTSS 42
Risk sharing:
Risk corridors in first year only43
Care Delivery
Model:
One Care plans will provide patient-centered medical homes that integrate primary care
and behavioral health services, care coordination, and clinical care management
Requires Long-Term Supports Coordinators from community-based organizations
independent of health plans as members of the care team
Participating
Health Plans:
-Essex. Franklin, Middlesex, Norfolk, and Plymouth (partial) counties: Commonwealth
Care Alliance
-Hampden and Hampshire counties: Commonwealth Care Alliance and Fallon Total
Care/Fallon Community Health Plan
-Suffolk County: Commonwealth Care Alliance and Network Health/Tufts Health Plan
-Worcester County: Commonwealth Care Alliance, Fallon Total Care/Fallon Community
Health Plan, and Network Health/Tufts Health Plan
Benefits:
Includes all Medicare and Medicaid state plan services except Medicare hospice and
Medicaid mental health and DD targeted case management services and mental health
rehabilitation option services; plans have discretion to offer flexible benefits as
appropriate to beneficiary needs; adds supplemental diversionary behavioral health and
community support services and expanded Medicaid state plan benefits (including
additional dental services)44
Continuity of
Care:
Beneficiaries must be allowed to maintain their current providers and service
authorizations for 90 days or until the plan completes an initial assessment, whichever is
longer
Ombuds
Program:
Massachusetts selected Disability Policy Consortium (to be supported by Health Care for
All and Consumer Quality Initiatives) as its demonstration ombudsman;45 not addressed in
MOU
Stakeholder
Engagement:
Same as California
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Illinois (60 days)
Internal health plan appeal: same as Illinois (all initial appeals must be filed with health
plan) except that appeals are to be resolved in 30 days (standard) or 72 hours (expedited)
External Medicare appeals: same as California (health plan automatically sends appeal to
Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare
Hearing and Appeals review
External Medicaid appeals: beneficiary may request fair hearing after adverse health plan
appeal
Appeals where Medicare and Medicaid services overlap: to be addressed in 3-way
contract; health plan bound by decision most favorable to beneficiary
Continued benefits pending appeal: health plans must provide continuing benefits for all
prior approved Medicare Parts A and B and Medicaid services while health plan appeals
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
25
are pending; beneficiaries may request continuation of previously authorized services for
Medicaid appeals while fair hearings are pending
Medicare Part D: same as California (existing Medicare Part D appeals process continues)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
26
MOU Signed:
April 3, 2014
3-way contract not yet available
Demonstration
Duration:
3 years
Jan. 1, 2015 to Dec. 31, 2017
Target Group:
Includes: an estimated 100,000 full benefit dual eligible beneficiaries age 21 and older
are eligible to enroll; those enrolled in the MI Choice § 1915(c) HCBS wavier, Money
Follows the Person, PACE, or an employer-sponsored Medicare Advantage plan may
participate if they disenroll from their existing program
Excludes: dual eligible beneficiaries previously disenrolled from Medicaid managed care
due to uncooperative or disruptive behavior, those who are eligible as Additional Low
Income Medicare Beneficiaries/Qualified Individuals or through a Medicaid spend down,
state psychiatric hospital residents, those with commercial HMO coverage, and those who
elect hospice services
Geographic
Area:
25 counties, grouped into 4 regions:
Region 1 (Upper Peninsula): Alger, Baraga, Chippewa, Delta, Dickinson, Gogebic,
Houghton, Iron, Keweenaw, Luce, Mackinac, Marquette, Menominee, Ontonagon, and
Schoolcraft counties
Region 4 (Southwest): Barry, Berrien, Branch, Calhoun, Cass, Kalamazoo, St. Joseph and
Van Buren counties
Region 7: Wayne county
Region 9: Macomb county
Enrollment:
Initial enrollment period is voluntary, followed by passive enrollment periods in which the
remaining beneficiaries in the target population will be automatically enrolled
Phase 1 voluntary enrollment: beneficiaries in regions 1 and 4 can opt into the
demonstration no earlier than Oct. 1, 2014, with enrollment effective Jan. 1, 2015. Phase
2 voluntary enrollment: beneficiaries in regions 7 and 9 can opt into the demonstration
no earlier than March 1, 2015 with enrollment effective May 1, 2015.
Phase 1 passive enrollment effective date April 1, 2015 for regions 1 and 4. Phase 2
passive enrollment effective date July 1, 2015 for regions 7 and 9. Beneficiaries will
receive notices no later than 60 and 30 days prior to passive enrollment.
Beneficiaries subject to Medicare reassignment effective Jan. 1, 2015 will not be passively
enrolled in the demonstration in 2015, but will be eligible for passive enrollment no
earlier than Jan. 1, 2016.
Plans designated by CMS as a past performance outlier or identified as consistently low
performing based on parent/sibling organization performance will not receive passive
enrollment.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
Michigan’s demonstration is contingent upon CMS approval of a § 1915(b) Medicaid
managed care waiver and concurrent § 1915(c) authority
Intelligent assignment for passive enrollment will consider previous managed care
enrollment and historic provider utilization
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
27
SHIP in partnership with AAAs and working with senior centers and CILs will provide
options counseling to beneficiaries.
Financing:
Medicare
baseline for
capitated
payments:
Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three,
except that if at least 1/3 of ICOs have year one losses exceeding 3% of revenue, the year
three savings percentage will be 3%) applied upfront to baseline Medicare and Medicaid
contributions; capitation rate quality withhold same as in California (1% in year 1, 2% in
year 2, 3% in year 3); all ICO subcontracts with PIHPs must reward the PIHP when ICO
achieves withheld amounts; state will phase-in separate quality withhold process specific
to PIHP performance after year one
Same as California except that Medicare Advantage risk score coding intensity adjustment
factor will apply beginning in 201546
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Same as California
Medicaid risk
adjustment:
Rating categories based on level of care47 with financial incentives for HCBS over
institutional care
Risk sharing:
Risk corridors in year 1;48 MLR of 85% in years 2 and 3; risk sharing does not apply to
services separately funded by direct payment from state to PIHPs
Care Delivery
Model:
Blend of Medicaid FFS claims for services covered in demonstration and capitation
payments for demonstration eligible beneficiaries in Medicaid managed care today
Integrated care organizations (ICOs) provide care coordination and integrated medical,
behavioral health, and LTSS directly or through subcontracts or partnership with local
Prepaid Inpatient Health Plans (PIHPs).
State will continue to contract directly with PIHPs for delivery of Medicaid behavioral
health services. ICOs must contract with regional PIHP for Medicare-funded behavioral
health services and to jointly coordinate care for enrollees with behavioral health,
substance use disorder and I/DD needs.
Enrollees have choice of ICO care coordinator. PIHP supports coordinators will be offered
to enrollees with behavioral health, substance use, or I/DD needs.
ICOs must provide LTSS supports coordination services. LTSS Supports Coordinators will
be offered to all enrollees who meet the NF LOC.
Participating
Health Plans:
Region 1: Upper Peninsula Health Plan
Region 4: CoventryCares of MI and Meridian Health Plan
Regions 7 and 9: AmeriHealth, CoventryCares of MI, Fidelis SecureCare, Midwest Health
Plan, Molina Healthcare, and United Healthcare49
Participation is subject to plans meeting readiness review requirements.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
28
Benefits:
Includes all Medicare and Medicaid state plan services except Medicare hospice. Includes
§ 1915(c) home and community-based waiver services for enrollees who meet NF LOC;
also includes supplemental benefits not currently available under Medicaid state plan:
adaptive medical equipment and supplies, community transition services, fiscal
intermediary (to support self-direction), personal emergency response system, respite;
ICOs can offer flexible benefits as appropriate to enrollee needs; enrollees must be
offered option to choose own LTSS providers with an established individualized budget
maintained by enrollee with support from fiscal intermediary
Continuity of
Care:
For enrollees in habilitation supports waiver and those receiving PIHP services: maintain
current provider for 180 days or continue with single case agreement; existing care plans
and prior authorizations continue until authorization ends or 180 days from enrollment,
whichever is sooner except that home health and state plan PCS level of services and
providers continue for 180 days; current waiver service providers and service level
continue unless changed through person-centered planning process.
For other enrollees: maintain current provider for 90 days or continue with single case
agreement; existing care plans and prior authorizations continue until authorization ends
or 180 days, whichever is sooner, except that home health and state plan PCS continue
for 90 days; enrollees in NFs may remain in that facility through ICO contract or single
case agreement or on out-of-network basis for duration of demonstration or until enrollee
chooses to relocate; MI Choices HCBS waiver services and providers continue for 90 days
unless changed during person-centered planning.
Ombuds
Program:
State will establish ombuds program to provide individual advocacy and systemic
oversight
Stakeholder
Engagement:
Each ICO must establish at least one advisory board that meets at least quarterly and a
process for that board to provide input to the HMO governing board. The advisory board
should include a mix of enrollees, caregivers and key community stakeholders, with 1/3
of the board composed of enrollees. ICOs must accommodate and support the advisory
board members by arranging necessary transportation, appropriate communications, and
other measures to ensure and encourage their full participation. Advisory board members
will be elected.
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: 90 days
Internal health plan appeal: initial Medicare appeals to ICO; initial Medicaid appeals to
ICO or state; ICOs must resolve standard appeals within 30 days and expedited appeals
within 72 hours
External Medicare appeals: appeals automatically forwarded to IRE, then enrollee can
request ALJ hearing
External Medicaid appeals: enrollee may request state fair hearing after ICO appeal or
enrollee may bypass ICO appeal and immediately request state fair hearing
Appeals where Medicare and Medicaid services overlap: enrollees may file appeal through
Medicare or Medicaid appeals process or both
Continued benefits pending appeal: Medicare and Medicaid benefits continue pending
internal ICO appeal
Medicare Part D appeals: remain unchanged
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
29
MOU Signed:
Sept. 12, 2013
Demonstration
Duration:
3 years
Sept. 13, 2013 to Dec. 31, 2016
Target Group:
Includes: an estimated 36,000 full benefit dual eligible beneficiaries age 65 and older
who are enrolled in Minnesota’s Senior Health Options Program
Geographic
Area:
Statewide
Enrollment:
Voluntary; the demonstration does not involve passive enrollment. The demonstration
will use an integrated enrollment system in which beneficiaries enroll and disenroll from
Medicare and Medicaid managed care simultaneously using an integrated form, notice,
and process.
Financing:
Minnesota’s demonstration will not test one of CMS’s financial alignment models.
Instead, the state will maintain its existing integrated capitated payment and delivery
system involving Medicaid MCOs that also qualify as Medicare Advantage D-SNPs
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
The demonstration maintains the state’s existing capitated financing arrangements
through separate plan contracts with CMS and with the state. Plans will continue to
comply with Medicare Advantage and Medicare Part D bid rules.
Same as above.
Same as above. Plan contracts with the state as Medicaid MCOs continue to apply.
Medicaid risk
adjustment:
Same as above.
Risk sharing:
Same as above.
Care Delivery
Model:
Benefits provided through Medicaid MCOs that contract with the state and that also
qualify as Medicare Advantage D-SNPs that contract with CMS. Plans may process an
integrated set of claims instead of differentiating between Medicare and Medicaid covered
services.
Plans will be allowed to integrate Medicare and Medicaid primary care payments to
facilitate Health Care Homes (HCHs) through Integrated Care System Partnerships (ICSPs)
between plans and providers to improve Medicare and Medicaid service coordination,
improve health outcomes, and help beneficiaries to remain in home or community-based
settings. HCHs will receive an additional payment for care coordination. ICSPs will allow
plans to use alternative payment approaches to integrate the HCH model with primary and
specialty care coordination arrangements for beneficiaries.
There are 3 ICSP models:
(1) HCH-Based Virtual ICSPs, which provide payments to primary care providers to
incentivize better care coordination;
(2) HCH or HCH alternative-based primary, acute, and/or LTC ICSPs, which build on the
health care home approach to further integrate primary and LTC coordination and
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
30
delivery; and
(3) Integration of Physical and Behavioral Health ICSPs, which allows further integration of
Medicaid mental health targeted case management services with the care coordination
required under Medicare and Medicaid HCHs and/or newly developing Medicaid
behavioral health homes to focus on reducing emergency room visits.
Participating
Health Plans:
Blue Plus, HealthPartners, Itasca Medical Care, Medica Health Plans, Metropolitan Health
Plan, PrimeWest Health, South Country Health Alliance, and UCare Minnesota
Benefits:
Medicare benefits will continue to be at least equivalent to those provided under Medicare
Parts A, B, and D. CMS and the state will explore options to reduce Part D co-pays for all
enrollees to test whether this will improve health outcomes and reduce overall health care
expenditures through improved medication adherence. Plans may provide additional
benefits to enrollees; the state will be involved in coordinating additional benefits to
ensure that these benefits are not included in the Medicaid capitation payment.
Medicaid benefits will continue to be provided per the Medicaid MCO contracts with plans.
Continuity of
Care:
N/A – demonstration will not change existing plan provider network arrangements.
Ombuds
Program:
The Minnesota Ombudsman for Managed Care will provide input on plan and system-wide
performance. No further detail specified.
Stakeholder
Engagement:
The CMS-state contract management team will review stakeholder input. No further detail
specified.
Appeals:
CMS and the state already have integrated elements of the appeals process in the Senior
Health Options program. The demonstration will add an integrated notice and appeal
timeframes.
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Michigan (90 days)
Internal health plan appeal: not specified in MOU
Integrated external appeals process: not specified in MOU
Appeals where Medicare and Medicaid services overlap: not specified in MOU
Continued benefits pending appeal: not specified in MOU
Medicare Part D: same as California (existing Medicare Part D appeals process continues)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
31
MOU Signed:
Aug. 26, 2013
3-way contract not yet available
Demonstration
Duration:
3 years
Jan. 1, 2015 to Dec. 31, 201750
Target Group:
Includes: an estimated 170,000 full benefit dual eligible beneficiaries age 21 and older in 8
counties who are eligible for a nursing home level of care and receiving facility-based LTSS
or who are eligible for the nursing home transition and diversion § 1915(c) waiver or who
require community-based LTSS for more than 120 days are eligible to enroll in the
demonstration
Excludes: dual eligible beneficiaries who reside in a state Office of Mental Health, psychiatric,
ICF/IDD, or alcohol/substance abuse long-term residential treatment facility or an assisted
living program, those receiving services from the state DD system, those eligible to reside in
an ICF/IDD but who choose not to, participants in the § 1915(c) DD and TBI HCBS waivers,
those expected to be eligible for Medicaid for less than 6 months, those eligible only for TBrelated, breast and cervical cancer or family planning expansion Medicaid services, those
receiving hospice services at the time of enrollment, non-elderly individuals who are
screened and require breast and cervical cancer treatment in the CDC early detection
program who do not have other creditable coverage, those eligible for emergency Medicaid,
and participants in the Foster Family Care demonstration
Geographic
Area:
8 counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
Enrollment:
Initial enrollment period is voluntary, followed by passive enrollment periods in which the
remaining beneficiaries in the target population will be automatically enrolled.
Beneficiaries receiving community-based LTSS and those in nursing facilities can voluntarily
enroll in the demonstration with enrollment effective no earlier than October 2014. 51 Those
that do not voluntarily enroll will be passively enrolled no earlier than Jan. 1, 2015. 52 The
MOU’s dates for notices in advance of voluntary and passive enrollment have not yet been
updated.
Passive enrollment for each group will be phased in over a minimum 4 month period.
Populations who will not be passively enrolled include Native Americans, people who are
eligible for the Medicaid buy-in for working people with disabilities and who are nursing
home eligible, Aliessa court ordered individuals, and enrollees in PACE, a Medicare
Advantage SNP for institutionalized beneficiaries, health homes, ACOs, the Independence at
Home demonstration and employer or union-sponsored coverage
Beneficiaries can opt out of the demonstration until the last day of the month prior to their
effective enrollment date and at any time after enrollment.
The MOU indicates that NY will submit conforming amendments to its § 1115 Partnership
Plan (MLTC) waiver and § 1915(c) nursing facility transition and diversion waiver. NY’s §
1115 waiver requires beneficiaries in the demonstration geographic area who need 120 days
of LTSS to enroll in Medicaid managed care.53
Intelligent assignment for passive enrollment will consider previous managed care
enrollment and historic provider utilization
Financing:
Capitated with savings percentage (1% in year one, 1.5% in year two, 3% in year three)
applied upfront to baseline Medicare and Medicaid contributions, except that savings in year
three will be reduced to 2.5% if at least 1/3 of plans experience losses exceeding 3% of
revenue in year 1, based on at least 15 months of data; capitation rate quality withhold same
as in California (1% in year 1, 2% in year 2, 3% in year 3)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
32
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Same as California except that Medicare Advantage risk score coding intensity adjustment
factor will apply beginning in CY 201454
Same as California
Blend of Medicaid MLTC capitated rates that would apply to enrollees in the demonstration
area and estimate of FFS costs for services excluded from MLTC rate
Medicaid risk
adjustment:
Rating categories55 risk adjusted similar to the model used for MLTC capitated rates
Risk sharing:
Required medical loss ratio of 85%; may require plans to maintain a minimum level of
reinsurance
Care Delivery
Model:
Fully Integrated Duals Advantage (FIDA) plans will perform assessments using the stateapproved assessment tool and provide person-centered care management and integrated
medical, behavioral health, substance use, and community and facility-based LTSS through
Interdisciplinary Teams. The Team makes coverage determinations and authorizes services,
which may not be modified by the plan outside the Team. Beneficiaries have the right to
choose and change their care managers.
Participating
Health Plans:
Aetna
Agewell
AlphaCare
Amerigroup
Amida
Catholic Managed Long Term Care, Inc. (Archcare)
Centerlight
Centers Plan for Healthy Living
Elderplan (Homefirst)
Elderserve
Fidelis Care of NY (NYS Catholic Health Plan)
GuildNet
Healthfirst (Managed Health, Inc.)
HHH Choices
HIP
Independence Care Systems
Integra
MetroPlus
Montefiore
North Shore LIJ HealthPlan, Inc.
Senior Whole Health
United Healthcare
Village Care MAX
VNYSNY Choice
Wellcare
Participation is subject to plans
meeting readiness review
requirements, and the final plan
announcement is expected in the
second quarter of CY 2014.56
Benefits:
Includes all Medicare and Medicaid services except hospice, out-of-network family planning,
directly observed therapy for TB and methadone maintenance; includes § 1115 Medicaid
MLTC services and § 1915(c) nursing facility diversion and transition HCBS; plans have
flexibility to enhance covered services with additional non-covered services to address
beneficiary needs and to cover items or services not traditionally covered by Medicare or
Medicaid that are necessary and appropriate for the beneficiary
Continuity of
Care:
Beneficiaries must maintain current providers and service levels for at least 90 days after
enrollment or until a care assessment has been completed by the FIDA plan, whichever is
later, except that beneficiaries must maintain current nursing facility providers for the
duration of the demonstration
Ombuds
Program:
NY is creating a new independent FIDA participant ombudsman to help beneficiaries access
care through the demonstration, provide individual advocacy and systemic oversight, and
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
33
gather and report data
Stakeholder
Engagement:
FIDA plans must establish at least one participant advisory committee that meets quarterly
and is open to all participants and a process for the committee to provide input to the plan.
Plans must demonstrate that beneficiaries with disabilities participate in the plan governance
structure. Plans also are encouraged to include beneficiaries on their boards of directors.
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Illinois (60 days)
Internal health plan appeal: same as Illinois (all initial appeals must be filed with health
plan) except MOU does not mention timeframes for appeal resolution; paper review unless
beneficiary requests in-person review; expedited review is available
Integrated external appeals process: all adverse internal health plan appeal decisions are
automatically sent to Integrated Hearing Officer external to the plan for a phone or in-person
hearing – expedited review is available; 60 days to appeal adverse Hearing Officer decision
to Medicare Appeals Council for paper review; adverse Appeals Council decision can be
appealed to federal district court
Appeals where Medicare and Medicaid services overlap: same process as above – NY is
establishing one integrated appeals process for all Medicare Parts A and B and Medicaid
appeals
Continued benefits pending appeal: benefits continue pending appeal during the internal
health plan appeal, the Integrated Hearing Officer hearing, and Medicare Appeals Council
review for all prior-approved services if the initial health plan appeal is requested within 10
days of the termination or modification notice
Medicare Part D: same as California (existing Medicare Part D appeals process continues to
apply)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
34
MOU Signed:
Dec. 11, 2012
3-way contract issued Feb. 11, 201457
Demonstration
Duration:
3 years
May 1, 201458 to Dec. 31, 2016
Target Group:
Includes: an estimated 115,000 full benefit dual eligible beneficiaries age 18 and older in
29 counties grouped into 7 regions are eligible to enroll
Excludes: dual eligible beneficiaries with other comprehensive coverage, those with
developmental disabilities who are served through an ICF/DD or § 1915(c) HCBS waiver,
those on a Medicaid spend down, and PACE or Independence at Home enrollees
Geographic
Area:
29 counties grouped into 7 regions:
-Central: Delaware, Franklin, Madison, Pickaway and Union counties
-East Central: Portage, Stark, Summit and Wayne counties
-Northeast: Cuyahoga, Geauga, Lake, Lorain, and Medina counties
-Northeast Central: Columbiana, Mahoning and Trumbull counties
-Northwest: Fulton, Lucas, Ottawa and Wood counties
-Southwest: Butler, Clermont, Clinton, Hamilton and Warren counties
-West Central: Clark, Greene and Montgomery counties
Enrollment:
Initial enrollment period is voluntary, followed by three passive enrollment periods in
which the remaining beneficiaries in the target population will be automatically enrolled
Beneficiaries first will be passively enrolled in a Medicaid managed care plan, with
enrollment effective May 1, 2014 in the Northeast region, June 1, 2014 in the Northwest,
Northeast Central, and Southwest regions; and July 1, 2014 in the East Central, Central,
and West Central regions. Beneficiaries also will be able to voluntarily enroll in the
demonstration for their Medicare benefits between May and Dec. 2014. Beneficiaries who
do not voluntarily enroll in the demonstration for their Medicare benefits will be passively
enrolled beginning in Jan. 2015.59 The MOU provides that beneficiaries will receive
notices 60 days prior to passive enrollment.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
Ohio may separately apply for a § 1915(b)/(c) waiver to require beneficiaries to enroll in a
Medicaid managed care plan if they opt out of the financial alignment demonstration
Intelligent assignment for passive enrollment will consider previous managed care
enrollment and historic provider utilization
Financing:
Capitated with savings percentage (1% in year one, 2% in year two, and 4% in year three)
applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality
withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Medicare
baseline for
capitated
payments:
Same as California
Medicare risk
adjustment:
Same as California
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
35
Medicaid
baseline for
capitated
payments:
Medicaid capitation rates under § 1915(b) waiver that would apply to beneficiaries who
are in target population but not enrolled in demonstration
Medicaid risk
adjustment:
Rating categories with financial incentives for HCBS over institutional care 60 and member
enrollment mix adjustment to account for plans with greater proportion of high risk/high
cost beneficiaries
Risk sharing:
Required minimum medical loss ratio of 90%
Care Delivery
Model:
Integrated Care Delivery System Plans will offer care management services to coordinate
medical, behavioral health, LTSS and social needs
Requires contracts with Area Agencies on Aging to coordinate home and communitybased waiver services for beneficiaries over age 60
Participating
Health Plans:
-Central and Southwest regions: Aetna and Molina
-East Central and Northeast Central regions: CareSource and United
-Northeast region: Buckeye/Centene, CareSource, and United
-Northwest region: Aetna and Buckeye/Centene
-West Central region: Buckeye/Centene and Molina
Benefits:
Includes all Medicare and Medicaid services, except Medicare hospice and Medicaid
habilitation services and targeted case management for beneficiaries with developmental
disabilities; includes Medicaid home and community-based waiver services except for
beneficiaries with developmental disabilities, with services to be defined in Ohio’s
expected § 1915(b)/(c) waiver application; plans have discretion to offer flexible benefits
as appropriate to beneficiary needs
Continuity of
Care:
Beneficiaries identified for high risk care management have a 90 day transition period for
maintaining current physician services; other beneficiaries have one year. HCBS waiver
enrollees maintain current waiver service levels for one year and providers for either one
year or 90 days, depending on the type of service
Ombuds
Program:
Ohio’s existing Office of the State Long-term Care Ombudsman will offer individual
advocacy and independent systemic oversight in the demonstration. Ohio has been
awarded CMS funding to support its ombuds program.61
Stakeholder
Engagement:
Same as California
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Michigan (90 days)
Internal health plan appeal: initial appeals for Medicare Parts A and B services must be
filed with health plan; initial appeals for Medicaid services may be filed with health plan or
beneficiary may directly request fair hearing; health plan to resolve appeals within 15
days (standard) or 72 hours (expedited)
External Medicare appeals: same as California (health plan automatically sends appeal to
Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare
Hearings and Appeals review)
External Medicaid appeals: beneficiary may request fair hearing initially or after health
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
36
plan appeal; fair hearings to be resolved within 90 days in year 1, 60 days in year 2 and
30 days in year 3
Appeals where Medicare and Medicaid services overlap: plan to be bound by decision
most favorable to beneficiary
Continued benefits pending appeal: benefits continue pending internal health plan
appeals and Medicaid fair hearings; payments for continued benefits while appeals are
pending are not recouped based on appeal outcome
Medicare Part D: same as California (existing Medicare Part D appeals process continues
to apply)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
37
MOU Signed:
Oct. 25, 2013
3-way contract not yet available
Demonstration
Duration:
3 years
July 1, 2014 to Dec. 31, 2017
Target Group:
Includes: an estimated 53,600 full benefit dual eligible beneficiaries ages 65 and older
who reside in the community at the time of enrollment (includes Community Choices
(elderly/disabled) waiver, HIV/AIDS waiver, and Mechanical Ventilation waiver participants)
are eligible to enroll; Medicare Advantage and PACE enrollees may enroll in the
demonstration if they disenroll from their current program; beneficiaries who transition
from an ICF/DD or nursing facility to the community may elect to enroll and also may be
eligible for passive enrollment; beneficiaries already enrolled in the demonstration who
later enter a nursing facility or hospice program or begin receiving ESRD services may
remain in the demonstration
Excludes: dual eligible beneficiaries with other comprehensive coverage, residents of an
ICF/DD or nursing facility and beneficiaries receiving hospice or ESRD services at the time
of demonstration eligibility determination, those on a Medicaid spend down, and those
receiving Medicaid HCBS through a waiver other than the 3 listed above
Geographic
Area:
Statewide, divided into two regions:
-Region 1/Upstate: Abbeville, Aiken, Anderson, Bamberg, Barnwell, Cherokee, Chester,
Edgefield, Fairfield, Greenville, Kershaw, Lancaster, Laurens, Lexington, McCormick,
Newberry, Oconee, Pickens, Richland, Saluda, Spartanburg, Union, and York counties
-Region 2/Coastal: Allendale, Beaufort, Berkeley, Calhoun, Charleston, Chesterfield,
Clarendon, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton,
Horry, Jasper, Lee, Marion, Marlboro, Orangeburg, Sumter, and Williamsburg counties
Enrollment:
Initial enrollment period is voluntary, followed by three passive enrollment periods in
which the remaining beneficiaries in the target population will be automatically enrolled
Voluntary enrollment will begin no sooner than July 1, 2014 and extend through Dec. 31,
2014. Passive enrollment will be phased in as follows: enrollment effective Jan. 1, 2015
for beneficiaries in the Upstate Region (Region 1) who are not served through HCBS
waivers; enrollment effective March 1, 2015 for beneficiaries in the Coastal Region
(Region 2) who are not served through HCBS waivers; and enrollment effective May 1,
2015 for beneficiaries statewide who receive HCBS waiver services. Beneficiaries subject
to Medicare reassignment effective Jan. 1, 2015 will be eligible for passive enrollment no
earlier than Jan. 1, 2016. Beneficiaries will receive enrollment notices 60 days and 30
days prior to passive enrollment
Beneficiaries may opt out of the demonstration until the last day of the month prior to
enrollment and thereafter on a monthly basis
South Carolina must submit a § 1932 Medicaid state plan amendment and concurrent
authority for the 3 affected § 1915(c) waivers prior to Jan. 1, 2014
Passive enrollment will be based on an “intelligent assignment” algorithm that will
consider existing provider relationships, including HCBS providers; previous history with
another Medicare Advantage or Medicaid managed care plan within the past year;
household members currently assigned to a demonstration plan; and relative case mix of
each demonstration plan
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
38
Financing:
Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three)
applied upfront to baseline Medicare and Medicaid contributions; capitation rate qualify
withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3); the state and
health plans will provide financial incentives to providers that achieve NCQA patient
centered medical home certification
Plans may receive up to $3,000 per enrollee as a one-time enhanced transition
coordination fee for successfully moving a beneficiary from a nursing facility to the
community for at least 12 months through SC’s Money Follows the Person program.
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Same as California62
Same as California
Historical state FFS spending for state plan and HCBS waiver services trended forward
Medicaid risk
adjustment:
Rating categories with financial incentive for 90 days following transition to community
from nursing facility and financial penalty for 90 days following transition from
community to nursing facility63
Risk sharing:
MLR of 85% required beginning in CY 2015
Care Delivery
Model:
Coordinated and Integrated Care Organizations (CICOs) must offer providers that are
medical homes and will offer care coordination of medical and behavioral health,
preventive services, prescription drugs, LTSS, social supports, and enhanced benefits.
The HCBS waiver case manager will be a member of the multidisciplinary care team,
responsible for advocating for LTC in the care coordination process.
HCBS authority will be transitioned from the state to plans over the course of the
demonstration: in phase I (July 1 to Dec. 31, 2014), the state will maintain contractual
relationships with HCBS providers, and plans will receive payment for those services and
process provider payments. The state will develop the waiver care plan and
recommended service authorizations with concurrence by the plan in a three-way
conference between the state reviewer, waiver care manager, and plan designee. If there
is disagreement, the plan may request review from the demonstration ombudsman which
has authority to make a final decision. The waiver case manager will work with the plan
care coordinator to integrate HCBS into the single overall care plan. In phase II (2015),
plans that have completed the benchmark review will assume responsibility for case
management services and most HCBS. Plans will perform LOC reassessments, contract
with HCBS providers, set provider rates subject to state minimum levels, develop HCBS
care plans and service authorizations with state concurrence, and subcontract with the
University of SC’s Center for Disability Resources for self-direction services. In phase III
(2016), plans that have completed the final benchmark review will assume all
responsibility needed to adequately coordinate HCBS, including self-direction, and may
elect to assume responsibility for provider credentialing and monitoring. A readiness
review will precede each phase.
Participating
Health Plans:
Absolute Total Care, Advicare, Molina Healthcare of South Carolina, Select Health of South
Carolina, WellCare Health Plans64
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
39
Benefits:
Plans will provide all Medicare and Medicaid benefits, other than Medicare hospice.
Includes home and community-based waiver services for Community Choices
(elderly/disabled), HIV/AIDS, and Mechanical Ventilation waivers. All enrollees who meet
the level of care criteria for HCBS will access waiver services without a waiting list
Plans must provide a new palliative care benefit for enrollees with a serious, chronic or
life-threatening illness who may not meet hospice criteria. Plans have discretion to offer
flexible benefits as appropriate to beneficiary needs
Continuity of
Care:
Beneficiaries must be able to maintain a current course of treatment with an out-ofnetwork provider, including behavioral health and LTSS, and must maintain current
service authorization levels for all direct care waiver services during a 180 day transition
period unless significant change has occurred and is documented during the LTC LOC
assessment.
Ombuds
Program:
State intends to support an independent ombuds program outside of the state Medicaid
agency to advocate and investigate on behalf of demonstration enrollees, safeguard due
process, identify systematic problems, and provide arbitration between the state and
plans as needed during the HCBS transition
Stakeholder
Engagement:
Same as California
Appeals:
Notice: Same as California (single integrated notice)
Timeframe to request initial appeal: Same as Illinois (60 days)
Internal health plan appeal: Same as Illinois (initial appeal must be filed with health plan)
except that expedited appeals are to be resolved within 72 hours
External Medicare appeals: same as California except that Office of Medicare Hearing and
Appeals review not mentioned in MOU
External Medicaid appeals: Same as Illinois except that beneficiary has 30 days from
internal appeal decision to request fair hearing for Medicaid-only services and
expedited appeals are to be resolved within 72 hours
Appeals where Medicare and Medicaid services overlap: if plan upholds denial of
overlapping Medicare-Medicaid services, appeal will be automatically forwarded to IRE.
Beneficiary then has 30 days from notice of right to fair hearing following IRE adverse
disposition to request fair hearing for Medicare-Medicaid overlapping services.
Continued benefits pending appeal: Medicare services will be required to continue
pending resolution of internal plan appeal. Medicaid services and Medicare-Medicaid
overlapping services will continue pending internal plan appeal if internal plan appeal is
filed within 10 days of notice. Medicaid services continue pending fair hearing disposition
if fair hearing is requested within 10 days of internal appeal decision. Medicare-Medicaid
overlapping services continue pending IRE decision and then during subsequent fair
hearing if requested within 10 days.
Medicare Part D appeals: Same as California (existing Medicare Part D appeals process
continues to apply)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
40
MOU Signed:
May 23, 2014
3-way contract not yet available
Demonstration
Duration:
3 years
March 1, 2015 to Dec. 31, 2018
Target Group:
Includes: an estimated 168,000 full benefit dual eligible beneficiaries with disabilities age
21 and older who qualify for SSI benefits or Medicaid home and community-based
STAR+PLUS waiver services; PACE and Independence at Home enrollees may enroll in the
demonstration if they disenroll from their current program; beneficiaries enrolled in a
Medicare Advantage plan not operated by the same parent organization that operates a
STAR+PLUS Medicare-Medicaid Plan may enroll in the demonstration if they disenroll from
their existing plan
Excludes: dual eligible beneficiaries who are residents of an ICF/DD or receive services
through the Community Living and Support Services, Deaf Blind with Multiple Disabilities
Program, Home and Community-Based Services or Texas Home Living Program § 1915(c)
waivers
Geographic
Area:
6 counties: Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant; CMS and the state may
change and/or add up to 2 additional counties to the demonstration if, before the
scheduled start date, a situation arises that would limit beneficiary choice or the quality or
availability of services would decrease in any service area – such a change is subject to
ongoing stakeholder discussions and must be effectuated by Jan. 1, 2016
Enrollment:
Initial enrollment period is voluntary, followed by passive enrollment phased-in over at
least 6 months during which the remaining beneficiaries in the target population will be
automatically enrolled
Voluntary enrollment will be effective March 1, 2015. For the first 6 months of the
demonstration, CMS and the state will monitor plans’ capacity to manage voluntary and
passive enrollments; depending on plan capacity, beneficiaries will be passively enrolled
into plans, considering the number of voluntary enrollments and the opt-out rate for each
plan. In Harris County, passive enrollment will not exceed 5,000 beneficiaries per month
per plan. In Bexar, Dallas, El Paso, Hidalgo, and Tarrant counties, passive enrollment will
not exceed 3,000 beneficiaries per plan per month. Beneficiaries subject to Medicare
reassignment effective Jan. 1, 2015 will be eligible for passive enrollment no earlier than
Jan. 1, 2016. Beneficiaries will receive enrollment notices 60 days and 30 days prior to
passive enrollment
Beneficiaries may opt out of the demonstration until the last day of the month prior to
enrollment and thereafter on a monthly basis
Texas’s existing § 1115 Medicaid demonstration waiver requires Medicaid managed care
enrollment; the waiver expires Sept. 30, 2016 and must be renewed to continue the
financial alignment demonstration
Passive enrollment will be based on an “intelligent assignment” algorithm that prioritizes
continuity of providers and/or services and considers beneficiaries’ previous managed
care enrollment and historic provider utilization
Financing:
Capitated with savings percentage (1.25% in year one(a), 2.75% in year one(b), 3.75% in
year two, 5.5% in year three) applied upfront to baseline Medicare and Medicaid
contributions; capitation rate qualify withhold same as in California (1% in year 1, 2% in
year 2, 3% in year 3)65
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
41
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Same as California66
Same as California
Capitation rates in the state’s Medicaid § 1115 managed care demonstration that would
otherwise apply, adjusted to add historical costs for benefits and Medicare cost-sharing
not included in the Medicaid demonstration capitation rates
Medicaid risk
adjustment:
Rating categories consistent with the state’s § 1115 Medicaid demonstration with
financial incentives for HCBS over NF care 67
Risk sharing:
Plans must pay an “Experience Rebate” to the state, which will be distributed back to the
Medicare and Medicaid programs, if plan net income before taxes is greater than specified
percentages for each demonstration year; 68 beginning in year 2, the amount of
administrative expenses used to determine net income before taxes will be capped
Care Delivery
Model:
STAR+PLUS Medicare-Medicaid Plans will provide care management of medical and
behavioral health, prescription drug, and LTSS.
Participating
Health Plans:
Bexar County: Amerigroup, Molina, Superior
Dallas County: Molina, Superior
El Paso County: Amerigroup, Superior
Harris County: Amerigroup, Molina, United
Hidalgo County: Health Spring, Molina, Superior
Tarrant County: Amerigroup, Health Spring69
Benefits:
Plans will provide all Medicare and Medicaid benefits, other than Medicare hospice.
Includes STAR+PLUS home and community-based waiver services
Plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of
Care:
Beneficiaries must be able to maintain their current providers and service authorizations
up to 90 days, with further details to be specified in the 3-way contract; in addition,
beneficiaries receiving LTSS at the time of enrollment, including nursing facility services,
will maintain service authorization up to 6 months, and beneficiaries being treated for a
terminal illness at the time of enrollment shall have continued access to covered services
for 9 months
Ombuds
Program:
The state Health and Human Services Commission Office of the Ombudsman will support
individual advocacy in the demonstration, provide feedback on plan performance issues
to CMS and the state, and gather and report data.
Stakeholder
Engagement:
Same as California
Appeals:
Notice: Same as California (single integrated notice)
Timeframe to request initial appeal: 60 days to file health plan appeal for Medicare or
Medicaid benefits; 90 days to request Medicaid fair hearing
Internal health plan appeal: initial Medicare appeal is filed with health plan; initial
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
42
Medicaid appeal is filed with health plan or beneficiary may directly request fair hearing;
health plan appeals must be resolved within 30 calendar days for standard appeals and
72 hours for expedited appeals except that appeals related to an ongoing emergency or
denial of continued hospitalization must be resolved no later than one business day
External Medicare appeals: same as California
External Medicaid appeals: Same as California except that Independent Medical Review
not mentioned
Appeals where Medicare and Medicaid services overlap: not mentioned in MOU
Continued benefits pending appeal: Medicare services will be required to continue
pending resolution of internal plan appeal. Medicaid services will continue pending
internal plan appeal and fair hearing if aid pending request is timely. Payments will not
be recouped based on the appeal outcome.
Medicare Part D appeals: Same as California (existing Medicare Part D appeals process
continues to apply)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
43
MOU Signed:
May 21, 2013
3-way contract issued Dec. 4, 201370
Demonstration
Duration:
3 years
April. 1, 2014 to Dec. 31, 201771
Target Group:
Includes: an estimated 78,600 full benefit dual eligible beneficiaries age 21 and older in
104 localities grouped into 5 regions are eligible to enroll; PACE and Independence at
Home enrollees may participate if they disenroll from their current program
Excludes: dual eligible beneficiaries with other comprehensive coverage, those served in a
state mental hospital, state hospital, ICF/DD, residential treatment facility or long stay
hospital (nursing facility residents are included), § 1915(c) HCBS waiver participants (other
than the Elderly or Disabled with Consumer Direction waiver), hospice patients, those with
end stage renal disease at the time of demonstration enrollment, those on a Medicaid
spend down, those who are eligible for Medicaid for less than 3 months, those whose only
Medicaid eligibility is retroactive, and enrollees in the Virginia Birth-Related Neurological
Injury Compensation Program or the Money Follows the Person Program
Geographic
Area:
104 localities in 5 regions:72
-Central Virginia: Amelia, Brunswick, Caroline, Charles City, Chesterfield, Cumberland,
Dinwiddie, Essex, Goochland, Greensville, Hanover, Henrico, King and Queen, King
George, King William, Lancaster, Lunenburg, Mecklenburg, Middlesex, New Kent,
Northumberland, Nottoway, Powhatan, Prince Edward, Prince George, Richmond Co.,
Southampton, Spotsylvania, Stafford, Surry, Sussex, Westmoreland, Colonial Heights,
Emporia, Franklin City, Fredericksburg, Hopewell, Petersburg, Richmond City
-Northern Virginia: Arlington, Culpepper, Fairfax County, Fauquier, Loudoun, Prince
William, Alexandria, Fairfax City, Falls Church, City of Manassas, Manassas Park
-Tidewater: Accomack, Gloucester, Isle of Wight, James City County, Mathews,
Northampton, York , Chesapeake, Hampton, Newport News, Norfolk, Poquoson,
Portsmouth, Suffolk, Virginia Beach, Williamsburg
-Western/Charlottesville: Albemarle, Augusta, Buckingham, Fluvanna, Greene, Louisa,
Madison, Nelson, Orange, Rockingham, Charlottesville, Harrisonburg, Staunton,
Waynesboro
-Roanoke: Alleghany, Bath, Bedford County, Botetourt, Craig, Floyd, Franklin County,
Giles, Henry, Highland, Montgomery, Patrick, Pulaski, Roanoke County, Rockbridge,
Wythe, Bedford City, Buena Vista, Covington, Lexington, Martinsville, Radford, Roanoke
City, Salem
Enrollment:
Enrollment will be conducted in two phases. Each phase will include an initial voluntary
enrollment period, followed by passive enrollment in which the remaining beneficiaries in
the target population will be automatically enrolled
In Phase I (Central VA and Tidewater), voluntary enrollment will be effective no sooner
than April 2014 (as revised).73 Initial passive enrollment for remaining Phase I
beneficiaries will be effective July 2014.74 The dates for advance notice have not been
updated since CMS and the state decided to delay enrollment. Phase II
(Western/Charlottesville, Northern VA, and Roanoke) also will have voluntary and passive
enrollment periods, but the dates have not been updated to reflect the delay subsequent
to the MOU. Beneficiaries subject to Medicare drug plan reassignment effective January
2014 will not be passively enrolled in 2014.
Beneficiaries may opt of the demonstration prior to passive enrollment and thereafter on
a monthly basis
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
44
Virginia’s § 1932(a) state plan amendment has been approved by CMS and provides for
voluntary enrollment in Medicaid managed care.75 The state also must amend its §
1915(c) waivers affected by the demonstration in the next update or scheduled renewal,
whichever is sooner
Passive enrollment intelligent assignment will prioritize the following: (1) beneficiaries in
NFs will be assigned to a plan with that NF in-network; (2) beneficiaries in HCBS waiver will
be assigned to plan that includes current adult day health care provider in-network; (3) if
more than one plan includes NF or adult day health care provider, assignment to the plan
in which beneficiary has been assigned in the last 6 months; (4) other beneficiaries will be
assigned to a plan to which they have been assigned in the last 6 months
Financing:
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Capitated with savings percentage (1% in year one, 2% in year two, 4% in year three)
applied upfront to baseline Medicare and Medicaid contributions, except that savings in
year three will be reduced to 3% if 1/3 of plans experience losses exceeding 3% of
revenue in all regions in which those plans participate in year one based on at least 20
months of data;76 capitation rate quality withhold same as in California (1% in year 1, 2% in
year 2, 3% in year 3)
Same as California77
Same as California
Historical state spending for state plan and HCBS waiver services trended forward
Medicaid risk
adjustment:
Rating categories with financial incentives for HCBS over institutional care 78 and member
enrollment mix adjustment to account for plans with greater proportion of high risk/high
cost beneficiaries and to account for the relative risk/cost differences of major subpopulations (e.g. nursing facility residents and beneficiaries receiving HCBS)
Risk sharing:
Required minimum medical loss ratio of 90%
Care Delivery
Model:
Commonwealth Coordinated Care plans will provide care management services to
coordinate medical, behavioral health, substance use, LTSS, and social needs
Participating
Health Plans:
Humana Health Plan, VA Premier Health Plan, HealthKeepers
Benefits:
Includes all Medicare and Medicaid state plan services and Elderly or Disabled with
Consumer Direction § 1915 home and community-based waiver services except Medicaid
targeted case management services and case management services for beneficiaries in
assisted living (hospice patients are excluded from the demonstration target population);
in limited cases, dental services will be carved out of the demonstration; plans have
discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of
Care:
Beneficiaries retain access to current providers for 180 days from demonstration
enrollment; beneficiaries retain access to services in existing plans of care and prior
authorizations until authorizations expire or 180 days from demonstration enrollment,
whichever is sooner, except that beneficiaries in nursing facilities at the time of
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
45
demonstration implementation may remain as long as they continue to meet level of care
criteria, unless they prefer to move to another facility or the community
Ombuds
Program:
Virginia intends to support an independent ombuds outside of the state Medicaid agency
to advocate and investigate on behalf of demonstration enrollees, safeguard due process,
identify systemic problems, and gather and report data. Virginia has been awarded CMS
funding to support its ombuds program.79
Stakeholder
Engagement:
Plans must establish an independent beneficiary advisory committee that provides input
to the governing board and includes beneficiaries with disabilities in the plan governance
structure
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Illinois (60 days)
Internal health plan appeal: same as Illinois (initial appeal must be filed with health plan)
except that appeals are to be resolved in 30 days (standard) or 72 hours (expedited)
External Medicare appeals: same as California
External Medicaid appeals: beneficiary may request fair hearing within 60 days of plan
appeal decision; to be resolved within 90 days of hearing request in year 1, 75 days in
year 2, and 30 days in year 3
Appeals where Medicare and Medicaid services overlap: to be defined in 3-way contract;
will automatically be sent to IRE, and beneficiary also may request fair hearing; plan to be
bound by decision most favorable to beneficiary
Continued benefits pending appeal: same as Massachusetts (health plans must provide
continuing benefits for all prior approved Medicare Parts A and B and Medicaid services
while health plan appeals are pending; beneficiaries may request continuation of
previously authorized services for Medicaid appeals while fair hearings are pending
Medicare Part D: same as California (existing Medicare Part D appeals process continues
to apply)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
46
MOU Signed:
Oct. 24, 2012;
final demonstration agreement signed June 28, 201380
Demonstration
Duration:
3 years
July 1, 201381 to Dec. 31, 2016
Target Group:
Includes: an estimated 21,000 full benefit dual eligible beneficiaries who are considered
high cost/high risk and eligible for Medicaid health home services 82 statewide, except in 2
urban counties where the state proposes testing a capitated model, are eligible to enroll
in the managed FFS demonstration; Medicare Advantage and PACE enrollees and
beneficiaries receiving hospice services may participate if they disenroll from their
existing program
Excludes: dual eligible beneficiaries with other comprehensive coverage
Geographic
Area:
Statewide except in 2 urban counties (King and Snohomish), divided into the following
coverage areas:
-Coverage Area 1: Clallam, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, and
Thurston counties
-Coverage Area 2: Island, San Juan, Skagit, and Whatcom counties
-Coverage Area 4: Pierce County
-Coverage Area 5: Clark, Cowlitz, Klickitat, Skamania, and Wahkiakum counties
-Coverage Area 6: Adams, Chelan, Douglas, Ferry, Grant, Lincoln, Okanogan, Pend
Oreille, Stevens, Spokane, and Whitman counties
-Coverage Area 7: Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla and
Yakima counties
Enrollment:
Eligible beneficiaries are automatically enrolled in a health home network with
beneficiaries retaining the choice about whether to receive health home services
State is identifying eligible beneficiaries on a monthly basis and sending outreach
materials one month prior to passive enrollment; earliest effective enrollment date was
July 2013 for beneficiaries in coverage areas 4, 5, and 7 and Oct. 2013 for beneficiaries in
coverage areas 1, 2, and 6
CMS approved Washington’s Medicaid health home state plan amendment in June 2013
for counties in coverage areas 4, 5, and 783 and in Dec. 2013 for counties in coverage
areas 1, 2, and 684
Financing:
Managed FFS; providers continue to receive FFS reimbursement (except existing capitated
behavioral health plans continue); state eligible for retrospective performance payment if
savings targets and quality standards met
Medicare
baseline for
capitated
payments:
N/A
Medicare risk
adjustment:
N/A
Medicaid
baseline for
capitated
N/A
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
47
payments:
Medicaid risk
adjustment:
N/A
Risk sharing:
N/A
Care Delivery
Model:
Health home care coordination organizations coordinate all Medicare and Medicaid
services among existing primary, acute, specialist, behavioral health, and LTSS providers
Participating
Health Plans:
-Coverage Area 1: Molina Healthcare of Washington; provisional designation to
Community Health Plan of Washington, Coordinated Care Corporation, United Behavioral
Health, and UnitedHealthcare of Washington85
-Coverage Area 2: provisional designation to Community Health Plan of Washington,
Coordinated Care Corporation, Molina Healthcare of Washington, Northwest Regional
Council, and UnitedHealthcare of Washington86
-Coverage Area 4: Community Health Plan of Washington, United Behavioral Health
(Optum Pierce), and UnitedHealthcare of Washington87
-Coverage Area 5: Community Health Plan of Washington, Coordinated Care Corporation,
United Behavioral Health, and United Healthcare of Washington88
-Coverage Area 6: Molina Healthcare of Washington; provisional designation to
Community Choice Healthcare Network, Community Health Plan of Washington,
Coordinated Care Corporation, and UnitedHealthcare of Washington 89
-Coverage Area 7: Community Health Plan of Washington, Coordinated Care Corporation,
Southeast Washington Aging and Long-Term Care (Yakima County), United Behavioral
Health, and United Healthcare of Washington90
Provisional designation is conditioned on satisfactory submission of a corrective action
plan and implementation timeline
Benefits:
Adds Medicaid health home services but otherwise does not change Medicare and
Medicaid benefits packages
Continuity of
Care:
Beneficiaries will retain access to their current choice of Medicare and Medicaid providers
Ombuds
Program:
Not addressed in MOU
Stakeholder
Engagement:
Health home networks must ensure meaningful beneficiary input, with specifics to be
determined in the state’s health home network qualification process. State will include
beneficiaries on its advisory team.
Appeals:
No changes from existing Medicare and Medicaid appeals systems. State and health
home providers are to assist beneficiaries with exercising appeal rights.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
48
MOU Signed:
Nov. 25, 2013
3-way contract not yet finalized
Demonstration
Duration:
3 years
Feb. 1, 2015 to Dec. 31, 201791
Target Group:
Includes: an estimated 27,000 full benefit adult dual eligible beneficiaries ages 21 and
older in 2 urban counties are eligible to enroll in the capitated demonstration; includes
Aging and Long-Term Support Administration Community Options Program Entry System
(COPES) § 1915(c) HCBS waiver enrollees; beneficiaries who receive Medicaid personal care
services, including those with developmental disabilities; and those in a Medicare
Advantage plan operated by the same organization as a demonstration plan; PACE
participants and beneficiaries in a Medicare Advantage plan operated by a parent company
that is not offering a demonstration plan may enroll in the demonstration if they disenroll
from their current program
Excludes: dual eligible beneficiaries with developmental disabilities who receive
institutional care or DD HCBS waiver services; Money Follows the Person participants;
those receiving hospice services at the time of enrollment; Medicaid spend down SLMB
Plus beneficiaries; and those with other comprehensive coverage
Geographic
Area:
King and Snohomish counties
Enrollment:
Voluntary enrollment effective no earlier than July 2014, with plan marketing no earlier
than June 2014
Three phases of passive enrollment effective no earlier than Sept. 2014 (phase 1), Nov.
2014 (phase 2), and Jan. 2015 (phase 3); enrollment of newly eligible beneficiaries will be
monthly as of Feb. 2015; notices will be sent 60 and 30 days prior to passive enrollment.
Beneficiaries will be randomly assigned to a passive enrollment phase, considering the
number of voluntary enrollments prior to phase 2 and the disenrollment rate for each plan.
American Indians and Alaska Natives are exempt from passive enrollment. Beneficiaries
subject to Medicare plan reassignment effective Jan. 2014 will not be subject to passive
enrollment in 2014. Beneficiaries eligible for Medicare plan reassignment effective Jan.
2015 who are eligible for the demonstration will be eligible for passive enrollment no
earlier than Jan. 2015.
Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter
on a monthly basis
The state must amend its § 1915(c) waiver by April 1, 2014 and submit a § 1932(a) state
plan amendment.
Passive enrollment plan assignments will consider the number of voluntary enrollments
prior to phase 2 and each plan’s disenrollment rate
ADRCs, operated by the AAAs, will provide independent enrollment assistance and options
counseling
Financing:
Capitated with savings percentage (1% in year one,92 2% in year two, and 3% in year three)
applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality
withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
49
Medicare
baseline for
capitated
payments:
Medicare risk
adjustment:
Medicaid
baseline for
capitated
payments:
Same as California except that Medicare Advantage risk score coding intensity adjustment
factor will apply beginning in calendar year 201493
Same as California
Historical state FFS and encounter data trended forward
Medicaid risk
adjustment:
Rating categories94
Risk sharing:
Minimum medical-loss ratio of 85-90%
Care Delivery
Model:
HealthPath Washington Medicare-Medicaid Integration Plans will provide health screenings
and risk assessments, care coordination, and intensive care management and integrate
medical, behavioral health, and LTSS.
Beneficiaries will be assigned to 1 of 3 tier levels based on screening, assessment, and
utilization data: Tier 1 (supported self-intervention – have care manager, care plan, and
interdisciplinary care team and receive referral assistance when appropriate); Tier 2
(disease/episodic care management – receive care management services dedicated to
problem-solving interventions and prevention and wellness messaging and conditionspecific educational materials and have care plan and care team); Tier 3 (intensive care
management for enrollees with special health care needs – have intensive care coordinator,
care plan, access to high touch intensive care management care team with face to face
interactions, and health action plan that identifies what the enrollee plans to do to improve
or self-manage health conditions and actions of the intensive care coordinator)
Care manager/intensive care coordinator shall make referral to state within 5 days of
identifying through the care coordination process or by the enrollee that there are unmet
LTSS needs. For beneficiaries newly eligible for HCBS waiver services, the demonstration
plan will be responsible for waiver service planning. For beneficiaries already eligible for
HCBS waiver services, the demonstration plan will maintain the existing HCBS waiver
service plan and providers through the authorization or continuity of care period,
whichever is later.
Participating
Health Plans:
Regence Blue Shield and United Health Care95
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
50
Benefits:
Includes all Medicare Parts A, B, and D services (except hospice), Medicaid state plan
services (except those listed below) and HCBS COPES waiver services
Services that remain FFS: 24 hour crisis intervention, involuntary treatment act-related
transportation for judicial review, abortion, transportation other than ambulance or HCBS
wavier, dental, child care/infant case management/maternity support, neurodevelopmental
center services, health department or family planning clinic services when client selfrefers, pharmaceuticals related to services under separate contract with state, weight loss
or reduction surgery, urinalysis for drug screening for pregnant or parenting women and
those received opiate substitution treatment, and prenatal diagnosis genetic counseling
Plans have discretion to offer flexible benefits as appropriate to address beneficiary needs
Plans may waive beneficiary Medicaid prescription drug and HCBS waiver service costsharing amounts
Continuity of
Care:
Beneficiaries shall decide what LTSS to receive to maintain independence and quality of
life, subject to coverage rules, and be able to hire, fire, and supervise personal care
workers
Beneficiaries must maintain current providers and service authorizations for 180 days or
until completion of care plan whichever is later, unless enrollee agrees to earlier transition,
for ESRD services, nursing facilities, adult family homes, and ALFs; and for 90 days or after
completion of a care plan whichever is later, unless enrollee agrees to earlier transition, for
all other services; plans will maintain LTSS providers (including home and communitybased waiver services and PCS) for the duration of the existing authorization period or the
demonstration continuity of care period, whichever is later (except 180 days for adult
family homes and ALFs); plans may choose to pay established out-of-network providers
indefinitely
Ombuds
Program:
State Office of Insurance Commissioner, Statewide Health Insurance Benefits Advisors, and
Consumer Advocacy Unit will provide individual advocacy and systemic oversight by
phone, online and through state health analysts
Stakeholder
Engagement:
Plans must establish an independent enrollee advisory committee that meets at least
quarterly and includes beneficiaries, caregivers, and key community stakeholders
Appeals:
Notice: same as California (single integrated notice)
Timeframe to request initial appeal: same as Michigan (90 days)
Internal health plan appeal: same as Illinois (initial appeals must be filed with plan);
standard appeals to be resolved within 14 calendar days of plan receipt of appeal unless
plan notifies enrollee that extension is necessary and in enrollee’s best interest; appeals
must be resolved within a maximum of 45 calendar days from plan receipt of appeal;
expedited appeals to be resolved no later than 72 hours of plan receipt of appeal
External Medicare appeals: same as California (health plan automatically sends appeal to
Medicare IRE if initial denial upheld; existing Medicare timeframes for appeal resolution
apply; beneficiary may then request ALJ, appeals board, and judicial review)
External Medicaid appeals: health plan automatically sends appeal to state Medicaid
Independent Review Organization if initial denial upheld; existing Medicaid timeframes for
appeal resolution apply; beneficiary may then request state administrative hearing;
beneficiary or plan may appeal to state Board of Appeals; beneficiary may then seek
judicial review in state court.
Appeals where Medicare and Medicaid services overlap: default to Medicare appeals
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
51
process, with further detail to be specified in 3-way contract; beneficiaries may choose to
request state IRO review concurrently with automatic IRE review; plan bound by ruling
most favorable to beneficiary.
Continued benefits pending appeal: Medicare and Medicaid benefits continue pending
appeal at plan level; for subsequent appeal levels, existing Medicaid rules apply to
Medicaid service appeals
Medicare Part D appeals: same as California (existing Medicare Part D appeals process
continues)
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
52
1
For background on the demonstrations, see Kaiser Commission on Medicaid and the Uninsured, Explaining the State Integrated Care
and Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Oct. 2012), available at http://www.kff.org/medicaid/issuebrief/explaining-the-state-integrated-care-and-financial/.
2
See Kaiser Commission on Medicaid and the Uninsured, Medicaid’s Role for Dual Eligible Beneficiaries (Aug. 2013), available at
http://www.kff.org/medicaid/issue-brief/medicaids-role-for-dual-eligible-beneficiaries/; Kaiser Family Foundation, Medicare’s Role
for Dual Eligible Beneficiaries (April 2012), available at http://www.kff.org/medicare/issue-brief/medicares-role-for-dual-eligiblebeneficiaries/.
3
Kaiser Commission on Medicaid and the Uninsured, Development of the Financial Alignment Demonstrations for Dual Eligible
Beneficiaries: Perspectives from National and State Disability Stakeholders (July 2013), available at http://kff.org/medicaid/issuebrief/development-of-the-financial-alignment-demonstrations-for-dual-eligible-beneficiaries-perspectives-from-national-and-statedisability-stakeholders/.
4
CMS, Medicare and Medicaid Coordination Office, Financial Alignment Initiative, Funding to Support Options Counseling for
Medicare-Medicaid Enrollees, http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FundingtoSupportOptionsCounselingforMedicare-MedicaidEnrollees-.html.
5
See, e.g., Virginia Commonwealth University Partnership for People with Disabilities, A Closer Look at the Centers’ for Medicare and
Medicaid Services’ Definition of Person-Centered Planning, available at http://www.medicaid.gov/mltss/docs/PCP-CMSdefinition0404.pdf.
6
State Medicaid spending qualifies for federal matching funds based upon the state’s Federal Medical Assistance Percentage (FMAP).
For more information about the FMAP, see Kaiser Commission on Medicaid and the Uninsured, Medicaid Financing: An Overview of
the Federal Medicaid Matching Rate (FMAP) (Sept. 2012), available at http://www.kff.org/health-reform/issue-brief/medicaidfinancing-an-overview-of-the-federal/.
7
CMS, Medicare-Medicaid Coordination Office, Financial Alignment Initiative, Funding to Support Ombudsman Programs,
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.
8
MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at 17 (Oct. 16, 2013), available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html; Calduals Ombudsman Resources,
available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf.
9
California’s three-way contract templates are available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-andMedicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/California.html; Illinois’ three-way
contract is available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/MedicareMedicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf; Massachusetts’ three-way contract is
available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/Downloads/MassachusettsContract.pdf; Ohio’s three-way contract is available at http://www.cms.gov/MedicareMedicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/Downloads/OhioContract.pdf; Virginia’s three-way contract is available at
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.
10
Washington’s final demonstration agreement is available at
http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
53
11
The states’ MOUs with CMS are available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-Coordination-Office/FinancialModelstoSupportStatesEffortsinCareCoordination.html. All
information in the Appendix is from the states’ MOUs unless otherwise indicated.
12
Templates available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/MedicareMedicaid-Coordination-Office/FinancialAlignmentInitiative/California.html.
13
California revised its start date from October 2013 to January 2014 and then to April 2014. CalDuals, “Coordinated Care Initiative to
begin no earlier than April 2014,” posted Aug. 16, 2013, available at http://www.calduals.org/2013/08/16/coordinated-care-initiativeto-begin-no-earlier-than-april-2014/; CalDuals, News & Updates, “Demo to start January 2014,” posted May 6, 2013, available at
http://www.calduals.org/news-and-updates/.
14
CCI Enrollment Timeline by County and Population (revised April 1, 2014), available at
http://www.calduals.org/2014/04/02/revised-enrollment-chart-by-county-available-here/.
15
Cal Duals, Proposed LA County Enrollment – Draft Revised Version (Feb. 18, 2014), available at
http://www.calduals.org/implementation/policy-topics/la-county-enrollment-strategy/.
16
Available at http://www.calduals.org/dhcs-cci-amendment-to-1115-waiver/.
17
In California’s demonstration, in calendar year 2014, CMS will apply “an appropriate Medicare Advantage coding intensity
adjustment reflective of all prime contractor plan enrollees.” In 2015 and 2016, CMS will apply “the prevailing Medicare Advantage
coding intensity adjustment factor.”
18
California’s Medicaid rating categories include institutionalized (90 or more days), HCBS High (high utilizers), HCBS Low (low
utilizers), and Community Well (no HCBS).
19
In Phase I, California’s risk adjustment methodology will be applied monthly and retroactively to match actual plan enrollment,
continuing through each county’s enrollment phase-in period (except San Mateo) for a minimum of one year, ending at the start of the
next fiscal quarter. Phase II will last for one fiscal quarter (except two quarters in San Mateo) in which the risk adjustment
methodology will be applied prospectively at the start of the quarter and risk category weighting will be based on enrollment in the
month preceding the quarter and applied retroactively. In Phase III, plan rates will be based on a targeted relative mix of the
population (based on plan enrollment leading up to the start of Phase III and including an assumed shift in population mix based on
assumptions about the plan’s ability to promote community services and prevent or delay institutional placement) and will not be
adjusted during the year (however, if the population mix results in greater than 2.5% impact on the Medicaid rate paid as compared to
the rate that would have been paid based on the actual mix, then the plan and Medicaid will share equally in any cost increases or
decreases beyond 2.5%, regardless of actual plan gain or loss).
20
California’s limited down-side risk corridor applies county-specific interim savings percentages to establish initial capitation rates; if
plan costs exceed the initial capitation rates (excluding Part D), Medicare and Medicaid will reimburse the plan 67% of the costs above
the initial capitation rates, provided that total federal and state payments to the plan cannot exceed the demonstration minimum
savings percentage for the applicable year. California’s limited up-side risk corridor is as follows: difference between demonstration
minimum savings percentage and county specific savings percentage, plans retain 100% (if county savings percentage is the same as the
demonstration minimum savings percentage, this band is based on the difference between the minimum savings percentage and
maximum demonstration savings percentages of 1.5% in year one, 3.5% in year two, and 5.5% in year three); from upper limit of first
band applying the same number of percentage points, Medicare and Medicaid share in 50% of plan savings and plan shares in the other
50%; for all amounts above the upper limit of the second band, plans retain 100%.
21
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.
22
Calduals Ombudsman Resources, available at http://www.calduals.org/implementation/policy-topics/ombudsman-resources/.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
54
23
Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/Downloads/IllinoisContract.pdf.
24
CMS announced that Illinois’ demonstration start date has been revised from October 2013 to January 2014. Email from Daniel
Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (May 31, 2013) (on file with author); subsequently,
Illinois changed its start date to February 2014, and then to March 2014. See Medicare-Medicaid Alignment Initiative Implementation
Status and County Plan Participation (March 1, 2014), available at
http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.
25
Illinois beneficiaries enrolled in a Medicare Advantage plan operated by the same parent organization as a demonstration plan will be
passively enrolled into that demonstration plan.
26
Medicare-Medicaid Alignment Initiative Implementation Status and County Plan Participation (March 1, 2014), available at
http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.
27
MMAI April 18, 2013, Stakeholders Meeting, Questions and Answers, items 61 and 62, available at
http://www2.illinois.gov/hfs/SiteCollectionDocuments/MMAI_QA_041813.pdf. Beneficiaries required to enroll in a Medicaid
managed care plan will be locked in for one year, after an initial 90 day change period, with an annual open enrollment period.
28
IL Dep’t of Healthcare and Family Services, Path to Transformation IL § 1115 waiver proposal, available at
http://www2.illinois.gov/hfs/publicinvolvement/1115/pages/1115.aspx#toc379811249.
29
Illinois’ Medicaid rating categories will be stratified by age (21-64 and 65+), geographic region, and care setting, including nursing
facility (except that the HCBS waiver rate applies for the first three months after transition from waiver to nursing facility), HCBS
waiver, waiver plus (for the first three months for beneficiaries moving from a nursing facility to a HCBS waiver), and community (do
not meet nursing home level of care, reside in a nursing facility or qualify for an HCBS waiver).
30
MMAI County Plan Participation,
http://www2.illinois.gov/hfs/PublicInvolvement/cc/mmai/Pages/MMAIImplementationStatus.aspx.
31
Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.
32
Available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reformplan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/related-information.html.
33
Although Massachusetts’ MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay
implementation until July 1, 2013, and again until October 1, 2013. Massachusetts Executive Office of Health and Human Services, One
Care Timeline Update, accessed June 6, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/servicesplanning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/relatedinformation.html.
34
MassHealth presentation at slide 7, Open Meeting, July 29, 2013, available at http://www.mass.gov/eohhs/provider/guidelinesresources/services-planning/national-health-care-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-andmedicaid/materials-from-previous-meetings.html.
35
Id.
36
MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 12 (Oct. 16, 2013), available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
55
37
MassHealth presentation, Open Meeting, Feb. 21, 2014, available at http://www.mass.gov/eohhs/docs/eohhs/healthcarereform/prev-meetings/140221-masshealth-presentation.pdf.
38
Massachusetts Executive Office of Health and Human Services, One Care Timeline Update, accessed Sept. 9, 2013, available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/related-information.html. Prior to announcing its revised enrollment effective
dates, Massachusetts had decided to delay passive enrollment of beneficiaries in the high community need and community high
behavioral health need categories until calendar year 2014. MassHealth presentation at slide 7, Open Meeting, May 17, 2013, available
at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-healthcare-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html; see also MassHealth
Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 17 (Oct. 16, 2013), available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.
39
Massachusetts revised its 2013 savings to zero. MassHealth presentation at slide 5, Open Meeting, May 17, 2013, available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html. Demonstration year one in
Massachusetts lasts from 2013 through December 2014.
40
Massachusetts anticipates savings of greater than 4% in year 3 (approximately 4.2%) to make up for foregone savings in year one.
Massachusetts Demonstration to Integrate Care for Dual Eligible Individuals, Updated Rate Report, May 15, 2013 at 18, available at
http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/state-fed-comm/duals-demo-cy2013-payment-rates.pdf.
41
Massachusetts’ Medicaid rating categories initially included facility-based care (long-term stay of more than 90 days), high
community needs (skilled need seven days a week; 2 or more ADL limitations and need for skilled nursing 3 or more days a week; or 4
or more ADL limitations), community high behavioral health (based on specific diagnosis of ongoing chronic condition), and
community other. Massachusetts subsequently refined its rating categories so that the high community needs and community high
behavioral health categories each will be split to separate beneficiaries with certain chronic diagnoses that lead to costs considerably
above average for the overall rating category, with the result that the high community needs group will be divided into highest
community need (for beneficiaries with certain diagnoses such as quadriplegia, ALS, and respirator dependence, that lead to costs
considerably above average for this rating category) and medium/high community need, and the community high behavioral health
group will be divided into community highest behavioral health (for beneficiaries with co-occurring substance abuse and serious mental
illness) and community medium/high behavioral health. MassHealth presentation at slide 7, Open Meeting, Feb. 21, 2014, available at
http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/140221-masshealth-presentation.pdf.
42
Massachusetts’ high cost risk pools apply to the facility-based care and high community needs rating categories. A portion of the base
Medicaid capitation rate for each of these rating categories will be withheld from all ICOs and placed into a risk pool that will be divided
among ICOs based on their percent of total costs above a threshold amount for select Medicaid LTSS.
43
Massachusetts’ risk corridor tiers have been revised as follows: greater than 20% gain or loss, plans bear entire risk/reward; 3%-20%
gain or loss, plans bear 50% of risk/reward and state and CMS share in other 50%; 1% to 3% gain or loss, plans bear 10% of risk/reward
and state and CMS share in other 90%; 0 to 1% gain or loss, plans bear entire risk/reward. MassHealth presentation at slide 3, Open
Meeting, June 28, 2013, available at http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-healthcare-reform-plan/federal-health-care-reform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.
44
Dental Services in One Care (Nov. 2013), available at http://www.communitycatalyst.org/initiatives-and-issues/initiatives/voicesfor-better-health/dual-agenda-newsletter/the-dual-agenda-december-4-2013/body/Dental-Services-in-One-Care_Nov-2013.pdf.
45
MassHealth Demonstration to Integrate Care for Dual Eligibles, Open Meeting presentation at slide 17 (Oct. 16, 2013), available at
http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/national-health-care-reform-plan/federal-health-carereform-initiatives/integrating-medicare-and-medicaid/materials-from-previous-meetings.html.
46
In 2015, CMS will apply an appropriate adjustment based on expected proportion of target population with prior Medicare Advantage
experience on a county-specific basis; in 2016, CMS will apply an appropriate adjustment reflective of all demonstration enrollees; after
2016, CMS will apply the prevailing adjustment to all enrollees.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
56
47
Michigan’s rating categories are tier 1 (meet NF LOC and occupy a NF bed certified for Medicare and Medicaid; separate rates for
publicly owned and privately owned NFs); tier 2 (meet NF LOC, do not live in NF, and enrolled in 1915(c) ICO waiver); tier 3 (do not
meet tier 1 or tier 2 criteria); rates may vary by age and will vary by geographic region. For up to 3 months following the transition of a
tier 2 or 3 enrollee to a NF, payment will be based on the tier 2 or 3 rate. A transition case rate will be paid after transition of a tier 1
enrollee to the community if the ICO received 3 consecutive tier 1 payments for the enrollee and provided transition services.
48
Michigan’s year 1 risk corridor bands are net income before taxes as % of revenue less than or equal to 3% or greater than 9%, ICO
bears entire risk/reward; greater than 3% and less than or equal to 9%, ICO bears 50%, Medicare bears percentage based on Medicare
share of combined capitation payments excluding Part D, Medicaid bears percentage based on Medicaid share of combined capitation
payments excluding Part D.
49
MI Dep’t of Comm’y Health, MI Health Link Region 4 Implementation Forum presentation (April 8, 2014), available at
http://www.michigan.gov/documents/mdch/MI_Health_Link__Forum_Presentation_4.08.14__452964_7.pdf.
50
While the MOU provided for a July 1, 2014 start date, CMS and the state subsequently modified the state date to October 2014 (email
from Daniel Farmer, CMS, Jan. 23, 2014, on file with author) and again to February 2015 (email from NY Medicaid Redesign Team,
July 2, 2014, on file with author).
51
Id.
52
MOU provided for Sept. 1, 2014, but CMS and the state subsequently modified to Jan. 1, 2015. Id.
Centers for Medicare and Medicaid Services, Special Terms and Conditions, New York State Dep’t of Health, Federal-State Health
Reform Partnership Medicaid Section 1115 Demonstration (April 1, 2013), available at http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Waivers/1115/downloads/ny/ny-f-shrp-ca.pdf.
53
54
In NY’s demonstration, in CY 2014 and 2015, CMS will apply “an appropriate coding intensity adjustment based on the proportion of
the target population with prior Medicare Advantage experience on a county-specific basis.” After CY 2015, CMS will apply “the
prevailing Medicare Advantage coding intensity adjustment to all FIDA Plan Participants.”
55
NY’s rating categories include community non-nursing home certifiable (more than 120 days community-based LTSS but do not
require nursing home level of care) and nursing home certifiable.
56
NY Fully Integrated Duals Advantage Demonstration Frequently Asked Questions, Question 6 (Sept. 2013), available at
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.
57
Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.
58
Ohio revised its demonstration start date from September 2013 to March 2014 and again to May 2014 for voluntary enrollment and
Jan. 1, 2015 for passive enrollment. Emails from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination
Office (May 31, 2013 and Jan. 23, 2014) (on file with author).
59
MyCare Ohio, Enrollment Update (Jan. 2014), available at
http://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/MyCareOhio/EnrollmentUpdate012014.pdf.
60
Ohio’s rating categories include community well (varies by age group (18-44, 45-64, 65+) and geographic region) and nursing facility
level of care (waiver enrollment or 100 or more days in nursing facility, single rate for each region, plan continues to receive nursing
facility rate for three months after a beneficiary is determined to no longer meet this level of care).
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
57
61
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.
62
In CY 2014, CMS will apply an “appropriate coding intensity adjustment based on the expected proportion of the target population
with prior Medicare Advantage experience on a county-specific basis.” In CY 2015, CMS will apply “the prevailing Medicare Advantage
coding intensity adjustment proportional to the anticipated proportion of Demonstration Enrollees in CY 2015 with prior Medicare
Advantage experience and/or Demonstration experience based on the Demonstration’s enrollment phase-in as of September 30, 2014.”
After CY 2015, CMS will apply “the prevailing Medicare Advantage coding intensity adjustment for all Enrollees.”
63
South Carolina’s rating categories include nursing facility based care (stay of more than 100 days); HCBS (meets level of care
requirement for nursing facility and/or HCBS waiver); HCBS plus (moving from nursing facility to waiver for first 3 months of
transition); and community (do not meet criteria for another category).
64
South Carolina Medicaid Healthy Connections Prime, Health Plan Announcement, available at https://msp.scdhhs.gov/SCDue2/.
65
Year 1(a) is March, 2015-Dec. 2105. Year 1(b) is Jan. 2016-Dec. 2016.
66
In CY 2015, CMS will apply an “appropriate coding intensity adjustment based on the expected proportion of the target population
with prior Medicare Advantage experience on a county-specific basis.” In CY 2016, CMS will apply “the prevailing Medicare Advantage
coding intensity adjustment proportionate to the anticipated percent of enrollees in CY 2016 with prior Medicare Advantage experience
and/or Demonstration experience based on the Demonstration’s enrollment phase-in as of September 30, 2015.” After CY 2016, CMS
will apply “the prevailing Medicare Advantage coding intensity adjustment” to all enrollees.
67
Texas’s rating categories include HCBS (includes those who receive HCBS waiver services and seniors and adults with disabilities who
qualify for NF LOC but do not reside in a NF), Other Community Care (receive Medicaid state plan services only and do not reside in
NF), and Nursing Facility (receive state plan services only and reside in NF). Rating categories may be updated to be consistent with the
§ 1115 demonstration, subject to CMS approval. For the first 3 months after a beneficiary transitions to a NF, the plan will be paid the
HCBS rate. For the first 3 months after a beneficiary transitions out of a NF to the community, the plan will be paid the NF rate.
68
Plans retain 100% of net income before taxes equal to or less than 3% of total plan revenues; the experience rebates that plans must
pay are 20% for the portion of net income before taxes greater than 3% and less than or equal to 5% of total plan revenues, 40% for the
portion greater than 5% and less than or equal to 7%, 60% for the portion greater than 7% and less than or equal to 9%, 80% for the
portion greater than 9% and less than or equal to 12%, and 100% for the portion greater than 12%. Net income before taxes is an
aggregate excess of revenues over allowable expenses.
69
Texas Health and Human Services Commission, Medicaid and CHIP, Dual Eligible Integrated Care Project, Geographic Area,
Participating Counties with number of clients covered and health plans, available at http://www.hhsc.state.tx.us/medicaid/managedcare/dual-eligible/.
70
Available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-MedicaidCoordination-Office/FinancialAlignmentInitiative/Downloads/OhioContract.pdf.
71
Email from Daniel Farmer, Special Assistant to the Director, Medicare-Medicaid Coordination Office (Jan. 23, 2014) (on file with
author).
72
Virginia Medicare-Medicaid Financial Alignment Demonstration Regions, updated Jan. 11, 2013, available at
http://www.dmas.virginia.gov/Content_atchs/altc/altc-anst6.pdf.
73
The MOU provides for voluntary enrollment effective Feb. 2014, but the state and CMS subsequently revised the effective date. Email
from Daniel Farmer (Jan. 23, 2014) (on file with author).
74
Id.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
58
75
Virginia state plan amendment 13-03 (approved June 12, 2013), available at http://www.medicaid.gov/State-resourcecenter/Medicaid-State-Plan-Amendments/Downloads/VA/VA-13-03-Att.pdf.
76
Demonstration year one in Virginia encompasses February 2014 through December 2015.
77
In Virginia’s demonstration, in calendar year 2014, CMS will apply “an appropriate coding intensity adjustment based on the
proportion of the target population with prior Medicare Advantage experience on a county-specific basis.” After calendar year 2014,
CMS will apply “the prevailing Medicare Advantage coding intensity adjustment for all [e]nrollees.”
78
Virginia’s rating categories include community well ages 21-64, community well age 65+, nursing facility level of care ages 21-64, and
nursing facility age 65+. Beneficiaries are eligible for the nursing facility categories if they are enrolled in an HCBS waiver or spend 20
or more consecutive days in a nursing facility. Plans will continue to receive the nursing facility rate for two months after a beneficiary
is determined to no longer meet that level of care. Rates within each category will vary by region.
79
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/FundingtoSupportOmbudsmanPrograms.html.
80
Washington’s final demonstration agreement is available at
http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.
81
Although Washington’s MOU with CMS provided for an April 1, 2013 start date, the state and CMS subsequently agreed to delay
implementation until July 1, 2013. Washington Health Care Authority Stakeholder Notice (Feb. 4, 2013), available at
http://www.communitycatalyst.org/doc_store/publications/StakeholdernoticeHealth%20Homes.pdf; see also Final Demonstration
Agreement between CMS and State of Washington Regarding a Federal-State Partnership to Test a Managed FFS Financial Alignment
Model for Medicare-Medicaid Enrollees (June 28, 2013), available at
http://www.adsa.dshs.wa.gov/duals/documents/WA%20Final%20Demonstration%20Agreement.pdf.
82
Chronic conditions included in WA’s health homes eligibility criteria include mental health conditions, substance use disorder,
asthma, diabetes, heart disease, cancer, cerebrovascular disease, coronary artery disease, dementia or Alzheimer’s disease, intellectual
disability, HIV/AIDS, renal failure, chronic respiratory conditions, neurological disease, gastrointestinal, hematological, and
musculoskeletal conditions. CMS/WA Final Demonstration Agreement at 5.
83
WA state plan amendment 13-08 (June 28, 2013), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-PlanAmendments/Downloads/WA/WA-13-08-Ltr.pdf.
84
WA state plan amendment 13-17 (Dec. 11, 2013), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-PlanAmendments/Downloads/WA/WA-13-17-HHSPA.pdf.
85
Washington State Health Care Authority, RFA #12-005 Qualified Health Homes Release C (Aug. 9, 2013),
http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncement_1_2_6.pdf.
86
Id.
87
Washington State Health Care Authority, RFA #12-005 Release A (Feb. 1, 2013),
http://www.hca.wa.gov/Documents/health_homes/coveragearea4_asa_announcement.pdf.
88
Washington State Heath Care Authority, RFA #12-005 Release B (April 30, 2013),
http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncementReleaseB.pdf.
Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared
59
89
Washington State Health Care Authority, RFA #12-005 Qualified Health Homes Release C (Aug. 9, 2013),
http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncement_1_2_6.pdf.
90
Washington State Heath Care Authority, RFA #12-005 Release B (April 30, 2013),
http://www.hca.wa.gov/Documents/health_homes/ASAAnnouncementReleaseB.pdf.
91
The MOU originally called for enrollment in July 2014, but Washington subsequently amended its earliest effective enrollment date
to February 1, 2015 (www.altsa.dshs.wa.gov/duals).
92
Demonstration year 1 in Washington is July 1, 2014 to Dec. 31, 2015.
93
In calendar year 2014, CMS will apply an “appropriate” coding intensity adjustment based on the proportion of the target population
with prior Medicare Advantage experience on a county-specific basis. In calendar year 2015, CMS will apply an appropriate coding
intensity adjustment reflective of all demonstration enrollees. After calendar year 2015, CMS will apply the prevailing Medicare
Advantage coding intensity adjustment.
94
Washington’s rating categories are medical and chemical dependency (institutional LOC and non-institutional LOC), mental health
(disabled according to SSI definition and non-disabled), and LTSS (institutional LOC, HCBS institutional level of care, non-institutional
LOC). In July and August 2014, rates will be based on an average mix of acuity with adjustments for geography, age and gender and will
be paid at the non-institutional rate (to the extent that beneficiaries who meet an institutional level of care enroll, institutional rates will
be applied retroactively). The mental health component of the rate will be risk adjusted based on historical claims and encounter data,
using age, gender, diagnosis and medication data. The LTSS component of the rate will be risk adjusted based on age, gender, and
functional assessment level. The medical/chemical dependency rate will not be risk adjusted by diagnosis. Rates will vary by county as
determined by the state and by age, and gender as determined necessary by the state and reviewed by CMS.
95
WA State Health Care Authority, “Health Care Authority, DSHS announce apparently successful bidders for HealthPath
Washington” (June 6, 2013), available at
http://www.altsa.dshs.wa.gov/duals/documents/Bidder%20awards%20on%20Strategy%20II%20duals%20project.pdf.
The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270
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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.